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Sample records for ambulatory care visits

  1. Pattern of Ambulatory Care Visits to Obstetrician-Gynecologists in Taiwan: A Nationwide Analysis

    Directory of Open Access Journals (Sweden)

    An-Min Lynn

    2015-06-01

    Full Text Available Although obstetrician-gynecologists (OB-GYNs are the main actors in the provision of health care to women, their practice patterns have rarely been analyzed. The current study investigated the nationwide ambulatory visits to OB-GYNs in Taiwan using the National Health Insurance Research Database. From the 1/500 sampling datasets indicating 619,760 ambulatory visits in 2012, it was found that 5.8% (n = 35,697 of the visits were made to OB-GYNs. Two-fifths of the services provided were performed by male OB-GYNs aged 50–59 years. Women of childbearing age accounted for more than half of the visits to OB-GYNs (57.2%, and elderly patients above 60 years accounted for only 7.7%. The most frequent diagnoses were menstrual disorders and other forms of abnormal bleeding from the female genital tract (13.1%. Anti-infective agents were prescribed in 15.1% of the visits to OB-GYNs. The study revealed the proportion of aging practicing OB-GYNs, and our detailed results could contribute to evidence-based discussions on health policymaking.

  2. Ambulatory care visits by Taiwanese dentists

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    Ying-Hwa Su

    2013-06-01

    Conclusion: There were inequalities in risks of ambulatory care use among Taiwan's dentists. Further studies should be conducted to investigate the causes responsible for the observed geographic and institutional variations in the risk of morbidity among dentists in Taiwan.

  3. Ambulatory Melanoma Care Patterns in the United States

    International Nuclear Information System (INIS)

    Ji, A. L.; Davis, S. A.; Feldman, S. R.; Fleischer, A. B.; Baze, M. R.; Feldman, S. R.; Feldman, S. R.; Fleischer, A. B.

    2013-01-01

    To examine trends in melanoma visits in the ambulatory care setting. Methods. Data from the National Ambulatory Medical Care Survey (NAMCS) from 1979 to 2010 were used to analyze melanoma visit characteristics including number of visits, age and gender of patients, and physician specialty. These data were compared to US Census population estimates during the same time period. Results. The overall rate of melanoma visits increased (ρ< 0.0001) at an apparently higher rate than the increase in population over this time. The age of patients with melanoma visits increased at approximately double the rate (0.47 year per interval year, ρ< 0.0001) of the population increase in age (0.23 year per interval year). There was a nonsignificant(ρ=0.19) decline in the proportion of female patients seen over the study interval. Lastly, ambulatory care has shifted towards dermatologists and other specialties managing melanoma patients and away from family/internal medicine physicians and general/plastic surgeons. Conclusions. The number and age of melanoma visits has increased over time with respect to the overall population, mirroring the increase in melanoma incidence over the past three decades. These trends highlight the need for further studies regarding melanoma management efficiency

  4. Ambulatory Care Visits to Pediatricians in Taiwan: A Nationwide Analysis

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    Ling-Yu Yang

    2015-11-01

    Full Text Available Pediatricians play a key role in the healthy development of children. Nevertheless, the practice patterns of pediatricians have seldom been investigated. The current study analyzed the nationwide profiles of ambulatory visits to pediatricians in Taiwan, using the National Health Insurance Research Database. From a dataset that was randomly sampled one out of every 500 records among a total of 309,880,000 visits in 2012 in the country, 9.8% (n = 60,717 of the visits were found paid to pediatricians. Children and adolescents accounted for only 69.3% of the visits to pediatricians. Male pediatricians provided 80.5% of the services and the main workforces were those aged 40–49 years. The most frequent diagnoses were respiratory tract diseases (64.7% and anti-histamine agents were prescribed in 48.8% of the visits to pediatricians. Our detailed results could contribute to evidence-based discussions on health policymaking.

  5. Differences in Treatment of Chlamydia trachomatis by Ambulatory Care Setting.

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    Pearson, William S; Gift, Thomas L; Leichliter, Jami S; Jenkins, Wiley D

    2015-12-01

    Chlamydia trachomatis (CT) is the most commonly reported sexually transmitted infection (STI) in the US and timely, correct treatment can reduce CT transmission and sequelae. Emergency departments (ED) are an important location for diagnosing STIs. This study compared recommended treatment of CT in EDs to treatment in physician offices. Five years of data (2006-2010) were analyzed from the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Surveys (NHAMCS), including the Outpatient survey (NHAMCS-OPD) and Emergency Department survey (NHAMCS-ED). All visits with a CT diagnosis and those with a diagnosis of unspecified venereal disease were selected for analysis. Differences in receipt of recommended treatments were compared between visits to physician offices and emergency departments using Chi square tests and logistic regression models. During the 5 year period, approximately 3.2 million ambulatory care visits had diagnosed CT or an unspecified venereal disease. A greater proportion of visits to EDs received the recommended treatment for CT compared to visits to physician offices (66.1 vs. 44.9 %, p < .01). When controlling for patients' age, sex and race/ethnicity, those presenting to the ED with CT were more likely to receive the recommended antibiotic treatment than patients presenting to a physician's office (OR 2.16; 95 % CI 1.04-4.48). This effect was attenuated when further controlling for patients' expected source of payment. These analyses demonstrate differences in the treatment of CT by ambulatory care setting as well as opportunities for increasing use of recommended treatments for diagnosed cases of this important STI.

  6. National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections.

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    Hersh, Adam L; Chambers, Henry F; Maselli, Judith H; Gonzales, Ralph

    2008-07-28

    Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs) in the United States. It is unknown whether this development has affected the national rate of visits to primary care practices and emergency departments (EDs) and whether changes in antibiotic prescribing have occurred. We examined visits by patients with SSTIs to physician offices, hospital outpatient departments, and EDs using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2005. We estimated annual visit rates for all SSTIs and a subset classified as abscess/cellulitis. For abscess/cellulitis visits, we examined trends in characteristics of patients and clinical settings and in antibiotic prescribing. Overall rate of visits for SSTIs increased from 32.1 to 48.1 visits per 1000 population (50%; P = .003 for trend), reaching 14.2 million by 2005. More than 95% of this change was attributable to visits for abscess/cellulitis, which increased from 17.3 to 32.5 visits per 1000 population (88% increase; P trend). The largest relative increases occurred in EDs (especially in high safety-net-status EDs and in the South), among black patients, and among patients younger than 18 years. Use of antibiotics recommended for CA-MRSA increased from 7% to 28% of visits (P < .001) during the study period. Independent predictors of treatment with these antibiotics included being younger than 45 years, living in the South, and an ED setting. The incidence of SSTIs has rapidly increased nationwide in the CA-MRSA era and appears to disproportionately affect certain populations. Although physicians are beginning to modify antibiotic prescribing practices, opportunities for improvement exist, targeting physicians caring for patients who are at high risk.

  7. Factors associated with ambulatory care sensitive emergency department visits for South Carolina Medicaid members with intellectual disability.

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    McDermott, S; Royer, J; Mann, J R; Armour, B S

    2018-03-01

    Ambulatory care sensitive conditions (ACSCs) can be seen as failure of access or management in primary care settings. Identifying factors associated with ACSCs for individuals with an Intellectual Disability (ID) provide insight into potential interventions. To assess the association between emergency department (ED) ACSC visits and a number of demographic and health characteristics of South Carolina Medicaid members with ID. A retrospective cohort of adults with ID was followed from 2001 to 2011. Using ICD-9-CM codes, four ID subgroups, totalling 14 650 members, were studied. There were 106 919 ED visits, with 21 214 visits (19.8%) classified as ACSC. Of those, 82.9% were treated and released from EDs with costs averaging $578 per visit. People with mild and unspecified ID averaged greater than one ED visit per member year. Those with Down syndrome and other genetic cause ID had the lowest rates of ED visits but the highest percentage of ACSC ED visits that resulted in inpatient hospitalisation (26.6% vs. an average of 16.8% for other subgroups). When compared with other residential types, those residing at home with no health support services had the highest ED visit rate and were most likely to be discharged back to the community following an ED visit (85.2%). Adults residing in a nursing home had lower rates of ED visits but were most likely to be admitted to the hospital (38.9%) following an ED visit. Epilepsy and convulsions were the leading cause (29.6%) of ACSC ED visits across all subgroups and residential settings. Prevention of ACSC ED visits may be possible by targeting adults with ID who live at home without health support services. © 2017 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.

  8. Sensitivity and specificity of obesity diagnosis in pediatric ambulatory care in the United States.

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    Walsh, Carolyn O; Milliren, Carly E; Feldman, Henry A; Taveras, Elsie M

    2013-09-01

    We examined the sensitivity and specificity of an obesity diagnosis in a nationally representative sample of pediatric outpatient visits. We used the 2005 to 2009 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care surveys. We included visits with children 2 to 18 years, yielding a sample of 48 145 database visits. We determined 3 methods of identifying obesity: documented body mass index (BMI) ≥95th percentile; International Classification of Diseases, Ninth Revision (ICD-9) code; and positive answer to the question, "Does the patient now have obesity?" Using BMI as the gold standard, we calculated the sensitivity and specificity of a clinical obesity diagnosis. Among the 19.5% of children who were obese by BMI, 7.0% had an ICD-9 code and 15.2% had a positive response to questioning. The sensitivity of an obesity diagnosis was 15.4%, and the specificity was 99.2%. The sensitivity of the obesity diagnosis in pediatric ambulatory visits is low. Efforts are needed to increase identification of obese children.

  9. Nonmelanoma skin cancer visits and procedure patterns in a nationally representative sample: national ambulatory medical care survey 1995-2007.

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    Wysong, Ashley; Linos, Eleni; Hernandez-Boussard, Tina; Arron, Sarah T; Gladstone, Hayes; Tang, Jean Y

    2013-04-01

    The rising incidence of nonmelanoma skin cancer (NMSC) is well documented, but data are limited on the number of visits and treatment patterns of NMSC in the outpatient setting. To evaluate practice and treatment patterns of NMSC in the United States over the last decade and to characterize differences according to sex, age, race, insurance type, and physician specialty. Adults with an International Classification of Diseases, Ninth Revision, diagnosis of NMSC were included in this cross-sectional survey study of the National Ambulatory Medical Care Survey between 1995 and 2007. Primary outcomes included population-adjusted NMSC visit rates and odds ratios of receiving a procedure for NMSC using logistic regression. Rates of NMSC visits increased between 1995 and 2007. The number of visits was significantly higher in men, particularly those aged 65 and older. Fifty-nine percent of NMSC visits were associated with a procedure, and the individuals associated with that visit were more likely to be male, to be seen by a dermatologist, and to have private-pay insurance. Nonmelanoma skin cancer visit rates increased from 1995 to 2007 and were higher in men than women. Visits to a dermatologist are more likely to be associated with a procedure for NMSC, and there may be discrepancies in treatment patterns based on insurance type and sex. © 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.

  10. Reimbursement and costs of pediatric ambulatory diabetes care by using the resource-based relative value scale: is multidisciplinary care financially viable?

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    Melzer, Sanford M; Richards, Gail E; Covington, Maxine L

    2004-09-01

    The ambulatory care for children with diabetes mellitus (DM) within an endocrinology specialty practice typically includes services provided by a multidisciplinary team. The resource-based relative value scale (RBRVS) is increasingly used to determine payments for ambulatory services in pediatrics. It is not known to what extent resource-based practice expenses and physician work values as allocated through the RBRVS for physician and non-physician practice expenses cover the actual costs of multidisciplinary ambulatory care for children with DM. A pediatric endocrinology and diabetes clinic staffed by faculty physicians and hospital support staff in a children's hospital. Data from a faculty practice plan billing records and income and expense reports during the period from 1 July 2000 to 30 June 2001 were used to determine endocrinologist physician ambulatory productivity, revenue collection, and direct expenses (salary, benefits, billing, and professional liability (PLI)). Using the RBRVS, ambulatory care revenue was allocated between physician, PLI, and practice expenses. Applying the activity-based costing (ABC) method, activity logs were used to determine non-physician and facility practice expenses associated with endocrine (ENDO) or diabetes visits. Of the 4735 ambulatory endocrinology visits, 1420 (30%) were for DM care. Physicians generated $866,582 in gross charges. Cash collections of 52% of gross charges provided revenue of $96 per visit. Using the actual Current Procedural Terminology (CPT)-4 codes reported for these services and the RBRVS system, the revenue associated with the 13,007 total relative value units (TRVUs) produced was allocated, with 58% going to cover physician work expenses and 42% to cover non-physician practice salary, facility, and PLI costs. Allocated revenue of $40.60 per visit covered 16 and 31% of non-physician and facility practice expenses per DM and general ENDO visit, respectively. RBRVS payments ($35/RVU) covered 46% of

  11. Factors associated with patient recall of key information in ambulatory specialty care visits: Results of an innovative methodology.

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    Laws, M Barton; Lee, Yoojin; Taubin, Tatiana; Rogers, William H; Wilson, Ira B

    2018-01-01

    While some studies have assessed patient recall of important information from ambulatory care visits, none has done so recently. Furthermore, little is known about features of clinical interactions which are associated with patient understanding and recall, without which shared decision making, a widely shared ideal for patient care, cannot occur. Our objective was to evaluate characteristics of patients and outpatient encounters associated with patient recall of information after one week, along with observation of elements of shared decision making. This was an observational study based on coded transcripts of 189 outpatient encounters, and post-visit interviews with patients 1 week later. Coding used three previously validated systems, adopted for this study. Forty-nine percent of decisions and recommendations were recalled accurately without prompting; 36% recalled with a prompt; 15% recalled erroneously or not at all. Provider behaviors hypothesized to be associated with patient recall, such as open-questioning and "teach back," were rare. Patients with less than high school education recalled 38% of items freely and accurately, while patients with a college degree recalled 65% (p total number of items to be recalled per visit, and percentage of utterances in decision-making processes by the provider ("verbal dominance"), were significant predictors of poorer recall. The item count was associated with poorer recall for lower, but not higher, educated patients.

  12. Acute Care Use for Ambulatory Care-Sensitive Conditions in High-Cost Users of Medical Care with Mental Illness and Addictions.

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    Hensel, Jennifer M; Taylor, Valerie H; Fung, Kinwah; Yang, Rebecca; Vigod, Simone N

    2018-01-01

    The role of mental illness and addiction in acute care use for chronic medical conditions that are sensitive to ambulatory care management requires focussed attention. This study examines how mental illness or addiction affects risk for repeat hospitalization and/or emergency department use for ambulatory care-sensitive conditions (ACSCs) among high-cost users of medical care. A retrospective, population-based cohort study using data from Ontario, Canada. Among the top 10% of medical care users ranked by cost, we determined rates of any and repeat care use (hospitalizations and emergency department [ED] visits) between April 1, 2011, and March 31, 2012, for 14 consensus established ACSCs and compared them between those with and without diagnosed mental illness or addiction during the 2 years prior. Risk ratios were adjusted (aRR) for age, sex, residence, and income quintile. Among 314,936 high-cost users, 35.9% had a mental illness or addiction. Compared to those without, individuals with mental illness or addiction were more likely to have an ED visit or hospitalization for any ACSC (22.8% vs. 19.6%; aRR, 1.21; 95% confidence interval [CI], 1.20-1.23). They were also more likely to have repeat ED visits or hospitalizations for the same ACSC (6.2% vs. 4.4% of those without; aRR, 1.48; 95% CI, 1.44-1.53). These associations were stronger in stratifications by mental illness diagnostic subgroup, particularly for those with a major mental illness. The presence of mental illness and addiction among high-cost users of medical services may represent an unmet need for quality ambulatory and primary care.

  13. Exploring the link between ambulatory care and avoidable hospitalizations at the Veteran Health Administration.

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    Pracht, Etienne E; Bass, Elizabeth

    2011-01-01

    This paper explores the link between utilization of ambulatory care and the likelihood of rehospitalization for an avoidable reason in veterans served by the Veteran Health Administration (VA). The analysis used administrative data containing healthcare utilization and patient characteristics stored at the national VA data warehouse, the Corporate Franchise Data Center. The study sample consisted of 284 veterans residing in Florida who had been hospitalized at least once for an avoidable reason. A bivariate probit model with instrumental variables was used to estimate the probability of rehospitalization. Veterans who had at least 1 ambulatory care visit per month experienced a significant reduction in the probability of rehospitalization for the same avoidable hospitalization condition. The findings suggest that ambulatory care can serve as an important substitute for more expensive hospitalization for the conditions characterized as avoidable. © 2011 National Association for Healthcare Quality.

  14. National Hospital Ambulatory Medical Care Survey

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    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...

  15. Delayed transition of care: a national study of visits to pediatricians by young adults.

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    Fortuna, Robert J; Halterman, Jill S; Pulcino, Tiffany; Robbins, Brett W

    2012-01-01

    Despite numerous policy statements and an increased focus on transition of care, little is known about young adults who experience delayed transition to adult providers. We used cross-sectional data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey between 1998 and 2008 to examine delayed transition among young adults ages 22 to 30. We defined delayed transition as continuing to visit a pediatrician after the age of 21 years. Overall, we found that 1.3% (95% confidence interval [CI] 1.1-1.7) of visits by young adults to primary care physicians were seen by pediatricians, approximately 445,000 visits per year. We did not find a significant change in delayed transition during the past decade (β = -.01; P = .77). Among young adults, visits to pediatricians were more likely than visits to adult-focused providers to be for a chronic disease (25.7% vs 12.6%; P = .002) and more likely to be billed to public health insurance (23.5% vs 14.1%; P = .01). In adjusted models, visits by young adults to pediatric healthcare providers were more likely associated with chronic disease (adjusted relative risk [ARR] 2.2; 95% CI 1.5-3.4), with public health insurance (ARR 1.9; 95% CI 1.3-2.9), or with no health insurance (ARR 1.9; 95% CI 1.1-3.4). Although most young adult visits were to adult providers, a considerable number of visits were to pediatricians, indicating delayed transition of care. There has been no substantial change in delayed transition during the past decade. Visits by young adults with chronic disease, public health insurance, or no health insurance were more likely to experience delayed transition of care. Copyright © 2012 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

  16. Improving visit cycle time using patient flow analysis in a high-volume inner-city hospital-based ambulatory clinic serving minority New Yorkers.

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    Dhar, Sanjay; Michel, Raquel; Kanna, Balavenkatesh

    2011-01-01

    Patient waiting time and waiting room congestion are quality indicators that are related to efficiency of ambulatory care systems and patient satisfaction. Our main purpose was to test a program to decrease patient visit cycle time, while maintaining high-quality healthcare in a high-volume inner-city hospital-based clinic in New York City. Use of patient flow analysis and the creation of patient care teams proved useful in identifying areas for improvement, target, and measure effectiveness of interventions. The end result is reduced visit cycle time, improved provider team performance, and sustained patient care outcomes. © 2010 National Association for Healthcare Quality.

  17. Toward a patient-centered ambulatory after-visit summary: Identifying primary care patients' information needs.

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    Clarke, Martina A; Moore, Joi L; Steege, Linsey M; Koopman, Richelle J; Belden, Jeffery L; Canfield, Shannon M; Kim, Min S

    2018-09-01

    The purpose of this study was to determine the information needs of primary care patients as they review clinic visit notes to inform information that should be contained in an after-visit summary (AVS). We collected data from 15 patients with an acute illness and 14 patients with a chronic disease using semi-structured interviews. The acute patients reviewed seven major sections, and chronic patients reviewed eight major sections of a simulated, but realistic visit note to identify relevant information needs for their AVS. Patients in the acute illness group identified the Plan, Assessment and History of Present Illness the most as important note sections, while patients in the chronic care group identified Significant Lab Data, Plan, and Assessment the most as important note sections. This study was able to identify primary care patients' information needs after clinic visit. Primary care patients have information needs pertaining to diagnosis and treatment, which may be the reason why both patient groups identified Plan and Assessment as important note sections. Future research should also develop and assess an AVS based on the information gathered in this study and evaluate its usefulness among primary care patients. The results of this study can be used to inform the development of an after-visit summary that assists patients to fully understand their treatment plan, which may improve treatment adherence.

  18. Ambulatory care registered nurse performance measurement.

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    Swan, Beth Ann; Haas, Sheila A; Chow, Marilyn

    2010-01-01

    On March 1-2, 2010, a state-of-the-science invitational conference titled "Ambulatory Care Registered Nurse Performance Measurement" was held to focus on measuring quality at the RN provider level in ambulatory care. The conference was devoted to ambulatory care RN performance measurement and quality of health care. The specific emphasis was on formulating a research agenda and developing a strategy to study the testable components of the RN role related to care coordination and care transitions, improving patient outcomes, decreasing health care costs, and promoting sustainable system change. The objectives were achieved through presentations and discussion among expert inter-professional participants from nursing, public health, managed care, research, practice, and policy. Conference speakers identified priority areas for a unified practice, policy, and research agenda. Crucial elements of the strategic dialogue focused on issues and implications for nursing and inter-professional practice, quality, and pay-for-performance.

  19. Weight loss in nonalcoholic Fatty liver disease patients in an ambulatory care setting is largely unsuccessful but correlates with frequency of clinic visits.

    Directory of Open Access Journals (Sweden)

    Anwar Dudekula

    Full Text Available Nonalcoholic fatty liver disease (NALFD is a leading cause of liver disease. Weight loss improves clinical features of NAFLD; however, maintenance of weight loss outside of investigational protocols is poor. The goals of this study were to characterize patterns and clinical predictors of long-term weight loss in ambulatory patients with NAFLD.We retrospectively reviewed 924 non-cirrhotic patients with NAFLD presenting to a liver clinic from May 1st 2007 to April 30th 2013. Overweight and obese patients were counseled on lifestyle modifications for weight loss as per USPSTF guidelines. The primary outcome was percent weight change between the first and last recorded visits: % weight change  =  (weightinitial - weightfinal/(weightinitial. Baseline BMI and percent BMI change were secondary measures. Predictors of weight loss were determined using logistic regression.The mean baseline BMI was 33.3±6.6 kg/m2, and the mean follow-up duration was 17.3±17.6 months. Most patients with NAFLD were in either overweight (26.1% or class I obesity (30.5% categories at baseline, while the prevalence of underweight and class III obesity was lower (0.2% and 15.4%, respectively. Overall, there was no change in mean weight or BMI during the follow-up period, and only 183 patients (19.8% lost at least 5% body weight during the follow up period. Independent predictors of weight loss included number of clinic visits and baseline BMI, and patients with higher baseline BMI required more clinic visits to lose weight.Weight loss is largely unsuccessful in NAFLD patients in the ambulatory care setting. Frequent clinical encounters are associated with weight reduction, especially among individuals with high baseline BMI. Future studies are required to define effective weight loss strategies in NAFLD patients.

  20. Brand name and generic proton pump inhibitor prescriptions in the United States: insights from the national ambulatory medical care survey (2006-2010).

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    Gawron, Andrew J; Feinglass, Joseph; Pandolfino, John E; Tan, Bruce K; Bove, Michiel J; Shintani-Smith, Stephanie

    2015-01-01

    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 HMO visits

  1. Disease Management Plus Recommended Care versus Recommended Care Alone for Ambulatory COPD Patients.

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    Kalter-Leibovici, Ofra; Benderly, Michal; Freedman, Laurence S; Kaufman, Galit; Molcho Falkenberg Luft, Tchiya; Murad, Havi; Olmer, Liraz; Gluch, Meri; Segev, David; Gilad, Avi; Elkrinawi, Said; Cukierman-Yaffe, Tali; Chen, Baruch; Jacobson, Orit; Key, Calanit; Shani, Mordechai; Fink, Gershon

    2018-03-01

    The efficacy of disease management programs in the treatment of patients with chronic obstructive pulmonary disease (COPD) remains uncertain. To study the effect of disease management (DM) added to recommended care (RC) in ambulatory COPD patients. In this trial, 1,202 COPD patients (age >40 years), with moderate to very severe airflow limitation were randomly assigned either to DM plus RC (study intervention) or to RC alone (control intervention). RC included follow-up by pulmonologists; inhaled long-acting bronchodilators and corticosteroids; smoking cessation intervention; nutritional advice and psychosocial support when indicated, and supervised physical activity sessions. DM, delivered by trained nurses during patients' visits to the designated COPD centers and remote contacts with the patients between these visits, included patient self-care education; monitoring patients' symptoms and adherence to treatment; provision of advice in case of acute disease exacerbation, and coordination of care vis-à-vis other healthcare providers. The primary composite endpoint was first hospital admission for respiratory symptoms or death from any cause. During 3,537 patient-years, 284 (47.2%) patients in the control group and 264 (44.0%) in the study intervention group had a primary endpoint event. The median (range) time elapsed until a primary endpoint event was 1.0 (0-4.0) years among patients assigned to the study intervention and 1.1 (0-4.1) years among patients assigned to the control intervention; adjusted hazard ratio, 0.92 (95%CI: 0.77 to 1.08). DM added to RC was not superior to RC alone in delaying first hospital admission or death among ambulatory COPD patients. Clinical trial registration available at www.clinicaltrials.gov, ID NCT00982384.

  2. The Association Between Internet Use and Ambulatory Care-Seeking Behaviors in Taiwan: A Cross-Sectional Study.

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    Hsieh, Ronan Wenhan; Chen, Likwang; Chen, Tsung-Fu; Liang, Jyh-Chong; Lin, Tzu-Bin; Chen, Yen-Yuan; Tsai, Chin-Chung

    2016-12-07

    Compared with the traditional ways of gaining health-related information from newspapers, magazines, radio, and television, the Internet is inexpensive, accessible, and conveys diverse opinions. Several studies on how increasing Internet use affected outpatient clinic visits were inconclusive. The objective of this study was to examine the role of Internet use on ambulatory care-seeking behaviors as indicated by the number of outpatient clinic visits after adjusting for confounding variables. We conducted this study using a sample randomly selected from the general population in Taiwan. To handle the missing data, we built a multivariate logistic regression model for propensity score matching using age and sex as the independent variables. The questionnaires with no missing data were then included in a multivariate linear regression model for examining the association between Internet use and outpatient clinic visits. We included a sample of 293 participants who answered the questionnaire with no missing data in the multivariate linear regression model. We found that Internet use was significantly associated with more outpatient clinic visits (P=.04). The participants with chronic diseases tended to make more outpatient clinic visits (PInternet may be associated with patients' increasing need for interpreting and discussing the information with health care professionals, thus resulting in an increasing number of outpatient clinic visits. In addition, the media literacy of Web-based health-related information seekers may also affect their ambulatory care-seeking behaviors, such as outpatient clinic visits. ©Ronan Wenhan Hsieh, Likwang Chen, Tsung-Fu Chen, Jyh-Chong Liang, Tzu-Bin Lin, Yen-Yuan Chen, Chin-Chung Tsai. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.12.2016.

  3. Beyond the clinic: redefining hospital ambulatory care.

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    Rogut, L

    1997-07-01

    Responding to changes in health care financing, government policy, technology, and clinical judgment, and the rise of managed care, hospitals are shifting services from inpatient to outpatient settings and moving them into the community. Institutions are evolving into integrated delivery systems, developing the capacity to provide a continuum of coordinated services in an array of settings and to share financial risk with physicians and managed care organizations. Over the past several years, hospitals in New York City have shifted considerable resources into ambulatory care. In their drive to expand and enhance services, however, they face serious challenges, including a well-established focus on hospitals as inpatient centers of tertiary care and medical education, a heavy reliance upon residents as providers of medical care, limited access to capital, and often inadequate physical plants. In 1995, the United Hospital Fund awarded $600,000 through its Ambulatory Care Services Initiative to support hospitals' efforts to meet the challenges of reorganizing services, compete in a managed care environment, and provide high-quality ambulatory care in more efficient ways. Through the initiative, 12 New York City hospitals started projects to reorganize service delivery and build an infrastructure of systems, technology, and personnel. Among the projects undertaken by the hospitals were:--broad-based reorganization efforts employing primary care models to improve and expand existing ambulatory care services, integrate services, and better coordinate care;--projects to improve information management, planning and testing new systems for scheduling appointments, registering patients, and tracking ambulatory care and its outcomes;--training programs to increase the supply of primary care providers (both nurse practitioners and primary care physicians), train clinical and support staff in the skills needed to deliver more efficient and better ambulatory care, prepare staff

  4. Redesigning ambulatory care business processes supporting clinical care delivery.

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    Patterson, C; Sinkewich, M; Short, J; Callas, E

    1997-04-01

    The first step in redesigning the health care delivery process for ambulatory care begins with the patient and the business processes that support the patient. Patient-related business processes include patient access, service documentation, billing, follow-up, collection, and payment. Access is the portal to the clinical delivery and care management process. Service documentation, charge capture, and payment and collection are supporting processes to care delivery. Realigned provider networks now demand realigned patient business services to provide their members/customers/patients with improved service delivery at less cost. Purchaser mandates for cost containment, health maintenance, and enhanced quality of care have created an environment where every aspect of the delivery system, especially ambulatory care, is being judged. Business processes supporting the outpatient are therefore being reexamined for better efficiency and customer satisfaction. Many health care systems have made major investments in their ambulatory care environment, but have pursued traditional supporting business practices--such as multiple access points, lack of integrated patient appointment scheduling and registration, and multiple patient bills. These are areas that are appropriate for redesign efforts--all with the customer's needs and convenience in mind. Similarly, setting unrealistic expectations, underestimating the effort required, and ignoring the human elements of a patient-focused business service redesign effort can sabotage the very sound reasons for executing such an endeavor. Pitfalls can be avoided if a structured methodology, coupled with a change management process, are employed. Deloitte & Touche Consulting Group has been involved in several major efforts, all with ambulatory care settings to assist with the redesign of their business practices to consider the patient as the driver, instead of the institution providing the care.

  5. An overview of anesthetic procedures, tools, and techniques in ambulatory care

    Directory of Open Access Journals (Sweden)

    Messieha Z

    2015-01-01

    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

  6. Achieving the AAAs of Ambulatory Care: Aptitude, Appeal, and Appreciation

    Science.gov (United States)

    Rybolt, Ann H.; Staton, Lisa J.; Panda, Mukta; Jones, Roger C.

    2009-01-01

    Background In the current health care environment more patient care has moved from in-hospital care to the ambulatory primary care settings; however, fewer internal medicine residents are pursuing primary care careers. Barriers to residents developing a sense of competency and enjoyment in ambulatory medicine include the complexity of practice-based systems, patients with multiple chronic diseases, and the limited time that residents spend in the outpatient setting. Objective In an effort to accelerate residents' ambulatory care competence and enhance their satisfaction with ambulatory practice, we sought to change the learning environment. Interns were provided a series of intensive, focused, ambulatory training sessions prior to beginning their own continuity clinic sessions. The sessions were designed to enable them to work confidently and effectively in their continuity clinic from the beginning of the internship year, and it was hoped this would have a positive impact on their perception of the desirability of ambulatory practice. Methods Improvement needs assessment after a performance, so we developed a structured, competency-based, multidisciplinary curriculum for initiation into ambulatory practice. The curriculum focused on systems-based practice, patient safety, quality improvement, and collaborative work while emphasizing the importance of continuity of care and long-term doctor-patient relationships. Direct observation of patient encounters was done by an attending physician to evaluate communication and physical examination skills. Systems of care commonly used in the clinic were demonstrated. Resources for practice-based learning were used. Conclusion The immersion of interns in an intensive, hands-on experience using a structured ambulatory care orientation curriculum early in training may prepare the intern to be a successful provider and learner in the primary care ambulatory setting. PMID:21975724

  7. Redesigning the regulatory framework for ambulatory care services in New York.

    Science.gov (United States)

    Chokshi, Dave A; Rugge, John; Shah, Nirav R

    2014-12-01

    Policy Points: The landscape of ambulatory care services in the United States is rapidly changing on account of payment reform, primary care transformation, and the rise of convenient care options such as retail clinics. New York State has undertaken a redesign of regulatory policy for ambulatory care rooted in the Triple Aim (better health, higher-quality care, lower costs)-with a particular emphasis on continuity of care for patients. Key tenets of the regulatory approach include defining and tracking the taxonomy of ambulatory care services as well as ensuring that convenient care options do not erode continuity of care for patients. While hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the public's interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the state's ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves. We explored and analyzed the regulation of ambulatory care services in New York in accordance with the available gray and peer-reviewed literature and legislative documents. The deliberations of the Public Health and Health Planning Council informed our review. The vision of high-performing ambulatory care should be rooted in the Triple Aim (better health, higher-quality care, lower costs), with a particular emphasis on continuity of care for patients. There is a pressing need to better define the taxonomy of ambulatory

  8. Performance measurement for ambulatory care: moving towards a new agenda.

    Science.gov (United States)

    Roski, J; Gregory, R

    2001-12-01

    Despite a shift in care delivery from inpatient to ambulatory care, performance measurement efforts for the different levels in ambulatory care settings such as individual physicians, individual clinics and physician organizations have not been widely instituted in the United States (U.S.). The Health Plan Employer Data and Information Set (HEDIS), the most widely used performance measurement set in the U.S., includes a number of measures that evaluate preventive and chronic care provided in ambulatory care facilities. While HEDIS has made important contributions to the tracking of ambulatory care quality, it is becoming increasingly apparent that the measurement set could be improved by providing quality of care information at the levels of greatest interest to consumers and purchasers of care, namely for individual physicians, clinics and physician organizations. This article focuses on the improvement opportunities for quality performance measurement systems in ambulatory care. Specific challenges to creating a sustainable performance measurement system at the level of physician organizations, such as defining the purpose of the system, the accountability logic, information and reporting needs and mechanisms for sustainable implementation, are discussed.

  9. Signs, symptoms, and treatment patterns across serial ambulatory cardiology visits in patients with heart failure: insights from the NCDR PINNACLE® registry.

    Science.gov (United States)

    Allen, Larry A; Tang, Fengming; Jones, Philip; Breeding, Tracie; Ponirakis, Angelo; Turner, Stuart J

    2018-05-03

    Due to a relative lack of outpatient heart failure (HF) clinical registries, we aimed to describe symptoms, signs, and medication treatment among ambulatory patients with heart failure (HF) over time. Using health records from 234 PINNACLE (Practice Innovation and Clinical Excellence) U.S. cardiology practices (2008-2014), serial visits for patients with HF were characterized. Symptoms, signs, and HF medications (angiotensin-converting enzyme inhibitors [ACEI], angiotensin receptor blockers [ARB], beta blockers [BB], and diuretics) were compared between visits. Among 763,331 patients with HF, 550,581 had ≥2 clinic visits < 1 year apart, with 2,998,444 visit pairs. In the 12 months following an index visit, patients had a mean of 2.5 ± 2.3 additional visits. Recorded index visit symptoms ranged from dyspnea (53.6%) to orthopnea (23.1%); signs ranged from peripheral edema (52.2%) to hepatomegaly (0.6%). Of those with ejection fraction < 40%, ACEI was prescribed in 58.6%, ARB in 18.5%, BB in 85.2%, and diuretics in 70.0%. Between-visit recorded changes were infrequent: dyspnea appeared in 3.8%, resolved in 2.7%; NYHA class increased in 2.9%, decreased in 2.9%; number of signs increased in 6.0%, decreased in 5.1%; ACEI/ARB or BB added in 6.4%, removed in 6.2%; diuretic added in 3.7%, removed in 3.8%. Changes in recorded symptoms were rarely associated with initiation or discontinuation in HF medication classes. Ambulatory HF care in U.S. cardiology practices seldom recorded changes in symptoms, signs, and medication class. Although templated medical records and absence of medication dosing likely underestimated the degree to which clinical changes occur over serial visits for HF, these PINNACLE data suggest opportunities for greater symptom-based and therapy-focused visits.

  10. Ambulatory Care Skills: Do Residents Feel Prepared?

    Directory of Open Access Journals (Sweden)

    Denise Bonds

    2002-10-01

    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.

  11. Single visit surgery for pediatric ambulatory surgical procedures: a satisfaction and cost analysis.

    Science.gov (United States)

    Olson, Jacob K; Deming, Lisa A; King, Denis R; Rager, Terrence M; Gartner, Sarah; Huibregtse, Natalie; Moss, R Lawrence; Besner, Gail E

    2017-10-10

    Single visit surgery (SVS) consists of same-day pre-operative assessment and operation with telephone post-operative follow-up. This reduces family time commitment to 1 hospital trip rather than 2-3. We began SVS for ambulatory patients with clear surgical indications in 2013. We sought to determine family satisfaction, cost savings to families, and institutional financial feasibility of SVS. SVS patients were compared to age/case matched conventional surgery (CS) patients. Satisfaction was assessed by post-operative telephone survey. Family costs were calculated as the sum of lost revenue (based on median income) and transportation costs ($0.50/mile). Satisfaction was high in both groups (98% for SVS vs. 93% for CS; p=0.27). 40% of CS families indicated that they would have preferred SVS, whereas no SVS families indicated preference for the CS option (p<0.001). Distance from the hospital did not correlate with satisfaction. Estimated cost savings for an SVS family was $188. Reimbursement, hospital and physician charges, and day-of-surgery cancellation rates were similar. SVS provides substantial cost savings to families while maintaining patient satisfaction and equivalent institutional reimbursement. SVS is an effective approach to low-risk ambulatory surgical procedures that is less disruptive to families, facilitates access to pediatric surgical care, and reduces resource utilization. Cost Effectiveness Study. Level II. Copyright © 2017 Elsevier Inc. All rights reserved.

  12. The Role of Ambulatory Care Pharmacists in an HIV Multidisciplinary Team within a Free and Bilingual Clinic

    Directory of Open Access Journals (Sweden)

    Radha S Vanmali

    2013-01-01

    Full Text Available 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: Types of interventions documented during the patient-pharmacist visit, categorized as medication review, patient education, or adherence monitoring. Results: Total of 32 patients accounted for 55 patient-pharmacist visits and 296 interventions. The most common interventions were medication review (66.9%, patient education (23.3%, and adherence monitoring (9.8%. Post-hoc analysis suggests Hispanic patients are more likely to be diagnosed with Acquired Immune Deficiency Syndrome (AIDS (P = 0.01, have current or history of opportunistic infection (OI (P=0.01, and have current or history of OI prophylaxis (P = 0.03. Adherence monitoring was less common amongst the non-Hispanics (7.1% compared to the Hispanic sub-population (16.5%, (P = 0.04. Conclusion: The role of ambulatory care pharmacists in a free and bilingual clinic goes beyond adherence monitoring. Pharmacists can be a valuable part of the patient care team by providing medication review and patient education for HIV and other co-morbidities within free clinics. Further research is warranted to assess outcomes and to further explore the underlying barriers to early HIV diagnosis and adherence within the Hispanic population.   Type: Original Research

  13. The Role of Ambulatory Care Pharmacists in an HIV Multidisciplinary Team within a Free and Bilingual Clinic

    Directory of Open Access Journals (Sweden)

    Ann M. Fugit, Pharm.D., BCPS

    2013-01-01

    Full Text Available 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: Types of interventions documented during the patient-pharmacist visit, categorized as medication review, patient education, or adherence monitoring. Results: Total of 32 patients accounted for 55 patient-pharmacist visits and 296 interventions. The most common interventions were medication review (66.9%, patient education (23.3%, and adherence monitoring (9.8%. Post-hoc analysis suggests Hispanic patients are more likely to be diagnosed with Acquired Immune Deficiency Syndrome (AIDS (P = 0.01, have current or history of opportunistic infection (OI (P=0.01, and have current or history of OI prophylaxis (P = 0.03. Adherence monitoring was less common amongst the non-Hispanics (7.1% compared to the Hispanic sub-population (16.5%, (P = 0.04. Conclusion: The role of ambulatory care pharmacists in a free and bilingual clinic goes beyond adherence monitoring. Pharmacists can be a valuable part of the patient care team by providing medication review and patient education for HIV and other co-morbidities within free clinics. Further research is warranted to assess outcomes and to further explore the underlying barriers to early HIV diagnosis and adherence within the Hispanic population.

  14. The ten successful elements of an ambulatory care center.

    Science.gov (United States)

    Watkins, G

    1997-01-01

    Experts in healthcare predict that in the future, over 80% of all care will be provided either in the home or ambulatory care centers. How radiology facilities position themselves for this shifting market is critical to their long-term success, even though it appears there are endless opportunities for providing care in this atmosphere. The ten most critical elements that healthcare providers must address to ensure their preparedness are discussed. Location is critical, particularly since patients no longer want to travel to regional medical centers. The most aggressive providers are building local care centers to serve specific populations. Ambulatory care centers should project a high tech, high touch atmosphere. Patient comfort and the appeal of the overall environment must be considered. Centers need to focus on their customers' needs in multiple areas of care. A quick and easy registration process, providing dressing gowns in patient areas, clear billing functions--these are all important areas that centers should develop. Physicians practicing in the ambulatory care center are key to its overall success and can set the tone for all staff members. Staff members must be friendly and professional in their work with patients. The hours offered by the center must meet the needs of its client base, perhaps by offering evening and weekend appointments. Keeping appointments on schedule is critical if a center wants satisfied customers. It's important to identify the target before developing your marketing plan. Where do your referrals come from? Look to such sources as referring physicians, managed care plans and patients themselves. Careful billing is critical for survival in the ambulatory care world. Costs are important and systems that can track cost per exam are useful. Know your bottom line. Service remains the central focus of all successful ambulatory care center functions.

  15. The value of registered nurses in ambulatory care settings: a survey.

    Science.gov (United States)

    Mastal, Margaret; Levine, June

    2012-01-01

    Ambulatory care settings employ 25% of the three million registered nurses in the United States. The American Academy of Ambulatory Care Nursing (AAACN) is committed to improving the quality of health care in ambulatory settings, enhancing patient outcomes, and realizing greater health care efficiencies. A survey of ambulatory care registered nurses indicates they are well positioned to lead and facilitate health care reform activities with organizational colleagues. They are well schooled in critical thinking, triage, advocating for patients, educating patients and families, collaborating with medical staff and other professionals, and care coordination. The evolving medical home concept and other health care delivery models reinforces the critical need for registered nurses to provide chronic disease management, care coordination, health risk appraisal, care transitions, health promotion, and disease prevention services. Recommendations are offered for organizational leaders, registered nurses, and AAACN to utilize nursing knowledge and skills in the pursuit of leading change and advancing health.

  16. Speak Up: Help Prevent Errors in Your Care: Ambulatory Care

    Science.gov (United States)

    ... Your Care Ambulatory Care To prevent health care errors, patients are urged to... SpeakUP TM Everyone has a ... he or she has confused you with another patient. P ay attention to the ... for their identification (ID) badges. • Notice whether your caregivers have washed ...

  17. Migraine-preventive prescription patterns by physician specialty in ambulatory care settings in the United States.

    Science.gov (United States)

    Takaki, Hiroko; Onozuka, Daisuke; Hagihara, Akihito

    2018-03-01

    Many adults with migraine who require preventive therapy are often not prescribed the proper medications. The most likely reason is that primary care physicians are unacquainted with preventive medications for migraine. The present study assessed the migraine-preventive prescription patterns in office visits using data from the National Ambulatory Medical Care Survey from 2006 to 2009 in the United States. Patients who were 18 years or older and diagnosed with migraine were included in the analysis. In accordance with the recommendations of the headache guidelines, we included beta-blockers, antidepressants, triptans for short-term prevention of menstrual migraine, and other triptans for acute treatment. Weighted visits of adults with migraine prescribed with preventive medication ranged from 32.8% in 2006 to 38.6% in 2009. Visits to primary care physicians accounted for 72.6% of the analyzed adult migraine visits. Anticonvulsants (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.14-0.57, p  < 0.001) and triptans for menstrual migraine (OR 0.50, 95% CI 0.28-0.91, p  = 0.025) were less frequently prescribed by primary care physicians compared with specialty care physicians, such as neurologists and psychiatrists. There were no significant differences in the prescription patterns of antidepressants and beta-blockers between primary and specialty care physicians. Beta-blockers were prescribed to patients with comorbidity of hypertension, and antidepressants were used by patients with comorbidity of depression. There are differences in the prescription patterns of certain type of preventive medications between primary care physicians and specialty care physicians.

  18. Migraine-preventive prescription patterns by physician specialty in ambulatory care settings in the United States

    Directory of Open Access Journals (Sweden)

    Hiroko Takaki

    2018-03-01

    Full Text Available Many adults with migraine who require preventive therapy are often not prescribed the proper medications. The most likely reason is that primary care physicians are unacquainted with preventive medications for migraine. The present study assessed the migraine-preventive prescription patterns in office visits using data from the National Ambulatory Medical Care Survey from 2006 to 2009 in the United States. Patients who were 18 years or older and diagnosed with migraine were included in the analysis. In accordance with the recommendations of the headache guidelines, we included beta-blockers, antidepressants, triptans for short-term prevention of menstrual migraine, and other triptans for acute treatment. Weighted visits of adults with migraine prescribed with preventive medication ranged from 32.8% in 2006 to 38.6% in 2009. Visits to primary care physicians accounted for 72.6% of the analyzed adult migraine visits. Anticonvulsants (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.14–0.57, p < 0.001 and triptans for menstrual migraine (OR 0.50, 95% CI 0.28–0.91, p = 0.025 were less frequently prescribed by primary care physicians compared with specialty care physicians, such as neurologists and psychiatrists. There were no significant differences in the prescription patterns of antidepressants and beta-blockers between primary and specialty care physicians. Beta-blockers were prescribed to patients with comorbidity of hypertension, and antidepressants were used by patients with comorbidity of depression. There are differences in the prescription patterns of certain type of preventive medications between primary care physicians and specialty care physicians.

  19. Trends and quality of care in outpatient visits to generalist and specialist physicians delivering primary care in the United States, 1997-2010.

    Science.gov (United States)

    Edwards, Samuel T; Mafi, John N; Landon, Bruce E

    2014-06-01

    Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain. To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs. Cross-sectional study and time trend analysis. Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997-2010. Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality. Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p = 0.04). The proportion of medical specialist visits in which the physician self-identified as the patient's PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p specialists. Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.

  20. National Ambulatory Medical Care Survey (NAMCS)

    Data.gov (United States)

    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 of...

  1. Prevalence of Polyherbacy in Ambulatory Visits to Traditional Chinese Medicine Clinics in Taiwan

    Science.gov (United States)

    Lin, Ming-Hwai; Chang, Hsiao-Ting; Tu, Chun-Yi; Chen, Tzeng-Ji; Hwang, Shinn-Jang

    2015-01-01

    Patients with a polyherbal prescription are more likely to receive duplicate medications and thus suffer from adverse drug reactions. We conducted a population-based retrospective study to examine the items of Chinese herbal medicine (CHM) per prescription in the ambulatory care of traditional Chinese medicine (TCM) in Taiwan. We retrieved complete TCM ambulatory visit datasets for 2010 from the National Health Insurance database in Taiwan. A total of 59,790 patients who received 313,482 CHM prescriptions were analyzed. Drug prescriptions containing more than five drugs were classified as polyherbal prescriptions; 41.6% of patients were given a polyherbal prescription. There were on average 5.2 ± 2.5 CHMs: 2.3 ± 1.1 compound herbal formula items, and 3.0 ± 2.5 single Chinese herb items in a single prescription. Approximately 4.6% of patients were prescribed 10 CHMs or more. Men had a lower odds ratio (OR) among polyherbal prescriptions (OR = 0.96, 95% confidence interval [CI] 0.92–0.99), and middle-aged patients (35–49 years) had the highest frequency of polyherbal prescription (OR = 1.19, 95% CI = 1.13–1.26). Patients with neoplasm, skin and subcutaneous tissue disease, or genitourinary system disease were more likely to have a polyherbal prescription; OR = 2.20 (1.81–2.67), 1.65 (1.50–1.80), and 1.52 (1.40–1.64), respectively. Polyherbal prescription is widespread in TCM in Taiwan. Potential herb interactions and iatrogenic risks associated with polyherbal prescriptions should be monitored. PMID:26287228

  2. Sustainable business models: systematic approach toward successful ambulatory care pharmacy practice.

    Science.gov (United States)

    Sachdev, Gloria

    2014-08-15

    This article discusses considerations for making ambulatory care pharmacist services at least cost neutral and, ideally, generate a margin that allows for service expansion. The four pillars of business sustainability are leadership, staffing, information technology, and compensation. A key facet of leadership in ambulatory care pharmacy practice is creating and expressing a clear vision for pharmacists' services. Staffing considerations include establishing training needs, maximizing efficiencies, and minimizing costs. Information technology is essential for efficiency in patient care delivery and outcomes assessment. The three domains of compensation are cost savings, pay for performance, and revenue generation. The following eight steps for designing and implementing an ambulatory care pharmacist service are discussed: (1) prepare a needs assessment, (2) analyze existing strengths, weaknesses, opportunities, and threats, (3) analyze service gaps and feasibility, (4) consider financial opportunities, (5) consider stakeholders' interests, (6) develop a business plan, (7) implement the service, and (8) measure outcomes. Potential future changes in national healthcare policy (such as pharmacist provider status and expanded pay for performance) could enhance the opportunities for sustainable ambulatory care pharmacy practice. The key challenges facing ambulatory care pharmacists are developing sustainable business models, determining which services yield a positive return on investment, and demanding payment for value-added services. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

  3. Characteristics of Office-based Physician Visits, 2015.

    Science.gov (United States)

    Ashman, Jill J; Rui, Pinyao; Okeyode, Titilayo

    2018-06-01

    In 2015, most Americans had a usual place to receive health care (85% of adults and 96% of children) (1,2). The majority of children and adults listed a doctor's office as the usual place they received care (1,2). In 2015, there were an estimated 990.8 million office-based physician visits in the United States (3,4). This report examines visit rates by age and sex. It also examines visit characteristics-including insurance status, reason for visit, and services-by age. Estimates use data from the 2015 National Ambulatory Medical Care Survey (NAMCS). All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

  4. Patient care delivery and integration: stimulating advancement of ambulatory care pharmacy practice in an era of healthcare reform.

    Science.gov (United States)

    Epplen, Kelly T

    2014-08-15

    This article discusses how to plan and implement an ambulatory care pharmacist service, how to integrate a hospital- or health-system-based service with the mission and operations of the institution, and how to help the institution meet its challenges related to quality improvement, continuity of care, and financial sustainability. The steps in implementing an ambulatory care pharmacist service include (1) conducting a needs assessment, (2) aligning plans for the service with the mission and goals of the parent institution, (3) collaborating with patients and physicians, (4) standardizing the patient care process, (5) proposing the service, (6) attaining the necessary resources, (7) identifying stakeholders, (8) identifying applicable quality standards, (9) defining competency standards, (10) planning for service payment, and (11) monitoring outcomes. Ambulatory care pharmacists have current opportunities to become engaged with patient-centered medical homes, accountable care organizations, preventive and wellness programs, and continuity of care initiatives. Common barriers to the advancement of ambulatory care pharmacist services include lack of complete access to patient information, inadequate information technology, and lack of payment. Ambulatory care pharmacy practitioners must assertively promote appropriate medication use, provide patient-centered care, pursue integration with the patient care team, and seek appropriate recognition and compensation for the services they provide. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

  5. Active ambulatory care management supported by short message services and mobile phone technology in patients with arterial hypertension.

    Science.gov (United States)

    Kiselev, Anton R; Gridnev, Vladimir I; Shvartz, Vladimir A; Posnenkova, Olga M; Dovgalevsky, Pavel Ya

    2012-01-01

    The use of short message services and mobile phone technology for ambulatory care management is the most accessible and most inexpensive way to transition from traditional ambulatory care management to active ambulatory care management in patients with arterial hypertension (AH). The aim of this study was to compare the clinical efficacy of active ambulatory care management supported by short message services and mobile phone technology with traditional ambulatory care management in AH patients. The study included 97 hypertensive patients under active ambulatory care management and 102 patients under traditional ambulatory care management. Blood pressure levels, body mass, and smoking history of patients were analyzed in the study. The duration of study was 1 year. In the active ambulatory care management group, 36% of patients were withdrawn from the study within a year. At the end of the year, 77% of patients from the active care management group had achieved the goal blood pressure level. That was more than 5 times higher than that in the traditional ambulatory care management group (P mobile phone improves the quality of ambulatory care of hypertensive patients. Copyright © 2012 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

  6. Trends in Ambulatory Prescribing of Antiplatelet Therapy among US Ischemic Stroke Patients: 2000–2007

    Directory of Open Access Journals (Sweden)

    Sudeep Karve

    2012-01-01

    Full Text Available Objective. Study objectives were to assess temporal trends and identify patient- and practice-level predictors of the prescription of antiplatelet medications in a national sample of ischemic stroke (IS patients seeking ambulatory care. Methods. IS-related outpatient visits by adults were identified using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for the years 2000–2007. We assessed prescribing of antiplatelet medications using the generic drug code and drug entry codes in these data. Temporal trends in antiplatelet prescribing were assessed using the Cochran-Mantel-Haenszel test for trend. Results. We identified 9.5 million IS-related ambulatory visits. Antiplatelet medications were prescribed at 35.5% of visits. Physician office prescribing of the clopidogrel-aspirin combination increased significantly from 0.5% in 2000 to 22.0% in 2007 (P=0.05, whereas prescribing of aspirin decreased from 17.9% to 7.0% (P=0.50 during the same period. Conclusion. We observed a continued increase in prescription of the aspirin-clopidogrel combination from 2000 to 2007. Clinical trial evidence suggests that the aspirin-clopidogrel combination does not provide any additional benefit compared with clopidogrel alone; however, our study findings indicate that even with lack of adequate clinical evidence physician prescribing of this combination has increased in real-world community settings.

  7. Ambulatory Phlebectomy

    Science.gov (United States)

    ... for Every Season How to Choose the Best Skin Care Products In This Section Dermatologic Surgery What is dermatologic ... for Every Season How to Choose the Best Skin Care Products Ambulatory Phlebectomy What is ambulatory phlebectomy? Ambulatory phlebectomy ...

  8. Transitioning the RN to Ambulatory Care: An Investment in Orientation.

    Science.gov (United States)

    Allen, Juliet Walshe

    2016-01-01

    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.

  9. A PDA based Point of Care E-Health Solution for Ambulatory Care

    Directory of Open Access Journals (Sweden)

    Daniel Walsh

    2005-11-01

    Full Text Available The adoption of PDAs and mobile communication is expected to provide a solution to the use of computer technology by healthcare workers at the point-of-care. The Australian National Health Information Strategy, Health Online, is providing national leadership for approaches to address the quality and availability of information to assist in the planning and delivery of care. One area for potential growth is the availability and capture of information at the point of care by healthcare providers. A key factor in the lack of adoption of systems, is that traditionally health care information systems have been designed for desktop computing whereas many healthcare workers are highly mobile. This paper discusses phase one of a larger, four-phase project which aims to develop information access applications at point-of-care for Ambulatory Care Services. The initial phase of the research (phase one involves workflow analysis, requirements specification and the development and testing of a system prototype to assess the feasibility of achieving increased efficiencies in workflow at the Ambulatory Care Service.

  10. Patient Satisfaction with Kimbrough Ambulatory Care Center

    Science.gov (United States)

    1997-02-01

    few are going to opt to change health plans. 14. SUBJECT TERMS PATIENT SATISFACTION; CONSUMER SATISFACTION; SURVEY 15. NUMBER OF PAGES 57 16...to address is overall patient satisfaction with Kimbrough’s current health care system. I surveyed customers on: how satisfied or dissatisfied they...research project was designed to determine how satisfied customers are with Kimbrough Ambulatory Care Center. A patient satisfaction survey developed by

  11. Ambulatory care pavilion takes its place out front by solving multiple needs.

    Science.gov (United States)

    Saukaitis, C A

    1994-09-01

    In sum, this structure exemplifies the fact that high-tech tertiary care medical centers can be user-friendly to the ambulatory health care consumer by serving their routine needs conveniently and efficiently. Says Gerald Miller, president of Crozer-Chester: "The ambulatory care pavilion has enabled Crozer to successfully and efficiently merge physicians' offices with institutional-based services and inpatient services. We are pleased with how the pavilion positions our medical center for the next century.

  12. Meta-synthesis on nurse practitioner autonomy and roles in ambulatory care.

    Science.gov (United States)

    Wang-Romjue, Pauline

    2018-04-01

    Many healthcare stakeholders view nurse practitioners (NPs) as an important workforce resource to help fill the anticipated shortage of 20,400 ambulatory care physicians that is expected by 2020. Multiple quantitative studies revealed the attributes of NPs' practice autonomy and roles. However, there is no qualitative meta-synthesis that describes the experiences of NPs' practice autonomy and roles. To describe and understand the experiences of NPs regarding their practice autonomy and roles in various ambulatory settings through the exploration of existing qualitative studies: meta-synthesis. A qualitative meta-synthesis was conducted to gain insight into ambulatory NPs' practice autonomy and roles through content analysis and reciprocal translation. Articles published between 2000 and 2017 were retrieved by searching 7 databases using the following key words: U.S. qualitative studies, advance practice nurses, NP role in ambulatory care, NP autonomy, and outpatient care. Autonomy, NPs' roles and responsibilities, practice relationships, and organizational work environment pressures are the four main themes that emerged from the content analysis of the nine selected qualitative studies. Within and between states, NPs' experiences with autonomy and NPs' roles are multifaceted depending on state regulations, practice relationships, and organizational work environments. © 2017 Wiley Periodicals, Inc.

  13. How Often Are Parents Counseled About Family Planning During Pediatric Visits? Results of a Nationally Representative Sample.

    Science.gov (United States)

    Venkataramani, Maya; Cheng, Tina L; Solomon, Barry S; Pollack, Craig Evan

    2017-07-01

    Maternal family planning plays an important role in child, maternal, and family health; children's health care providers are in a unique position to counsel adult caregivers regarding contraception and appropriate birth spacing. We sought to determine the prevalence of caregiver family planning counseling by children's health care providers during preventive care visits for infants and young children. Data from the National Ambulatory Medical Care Survey from 2009 to 2012 as well as National Hospital Ambulatory Medical Care Survey from 2009 to 2011 were analyzed to determine the weighted frequency of family planning/contraception counseling provided during preventive, primary care visits for children younger than the age of 2 years. Family planning/contraception counseling or education was documented in only 16 of 4261 preventive care visits in primary care settings for children younger than the age of 2 years, corresponding to 0.30% (95% confidence interval, -0.08% to 0.68%) of visits nationally. Similar frequencies were calculated for preventive visits with children younger than 1 year and with infants younger than 60 days of age. Despite Bright Futures' recommendations for children's health care providers to address caregiver family planning during well infant visits, documented counseling is rare. The results indicate that there are missed opportunities to promote family health in the pediatric setting. Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

  14. Ambulatory anesthetic care in children undergoing myringotomy and tube placement: current perspectives.

    Science.gov (United States)

    Robinson, Hal; Engelhardt, Thomas

    2017-01-01

    Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT) surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction. This review summarizes recently published studies about the long-term effects of general anesthesia in young children, novel approaches to preoperative fasting and simplified approaches to the assessment and management of emergence delirium (ED) and emergence agitation (EA). New developments in perioperative ambulatory care, including management of comorbidities and day care unit logistics, are discussed. Long-term follow-up of children exposed to general anesthesia before the age of 4 years has limited impact on academic achievement or cognitive performance and should not delay the treatment of common ENT pathology, which can impair speech and language development. A more liberal approach to fasting, employing a 6-4-0 regime allowing children fluids up until theater, may become an accepted practice in future. ED and EA should be discriminated from pain in recovery and, where the child is at risk of harm, should be treated promptly. Postoperative pain at home remains problematic in ambulatory surgery and better parental education is needed. Effective ambulatory care ultimately requires a well-coordinated team approach from effective preassessment to postoperative follow-up.

  15. Patient characteristics and trends in nontraumatic dental condition visits to emergency departments in the United States

    Directory of Open Access Journals (Sweden)

    Xiang Q

    2012-01-01

    Full Text Available Christopher Okunseri1, Elaye Okunseri1, Joshua M Thorpe2, Qun Xiang3, Aniko Szabo31Department of Clinical Services, Marquette University School of Dentistry, Milwaukee, WI, 2Division of Social and Administrative Sciences, University of Wisconsin, Madison School of Pharmacy, Madison WI, 3Division of Biostatistics, Department of Population Health, Medical College of Wisconsin, Milwaukee, WI, USAObjective: We examined trends and patient characteristics for non-traumatic dental condition (NTDC visits to emergency departments (EDs, and compared them to other ED visit types, specifically non-dental ambulatory care sensitive conditions (non-dental ACSCs and non-ambulatory care sensitive conditions (non-ACSCs in the United States.Methods: We analyzed data from the National Hospital Ambulatory Medical Care survey (NHAMCS for 1997 to 2007. We performed descriptive statistics and used a multivariate multinomial logistic regression to examine the odds of one of the three visit types occurring at an ED. All analyses were adjusted for the survey design.Results: NTDC visits accounted for 1.4% of all ED visits with a 4% annual rate of increase (from 1.0% in 1997 to 1.7% in 2007. Self-pay patients (32% and Medicaid enrollees (27% were over-represented among NTDC visits compared to non-dental ACSC and non-ACSC visits (P < 0.0001. Females consistently accounted for over 50% of all types of ED visits examined. Compared to whites, Hispanics had significantly lower odds of an NDTC visit versus other visit types (P < 0.0001. Blacks had significantly lower odds of making NDTC visits when compared to non-dental ACSC visits only (P < 0.0001. Compared to private insurance enrollees, Medicaid and self-pay patients had 2–3 times the odds of making NTDC visits compared to other visit types.Conclusion: Nationally, NTDC visits to emergency departments increased over time. Medicaid and self-pay patients had significantly higher odds of making NDTC visits.Keywords: emergency

  16. Ambulatory anesthetic care in children undergoing myringotomy and tube placement: current perspectives

    Directory of Open Access Journals (Sweden)

    Robinson H

    2017-04-01

    Full Text Available Hal Robinson, Thomas Engelhardt Department of Anaesthesia, Royal Aberdeen Children’s Hospital, Aberdeen, UK Purpose: Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction.Recent findings: This review summarizes recently published studies about the long-term effects of general anesthesia in young children, novel approaches to preoperative fasting and simplified approaches to the assessment and management of emergence delirium (ED and emergence agitation (EA. New developments in perioperative ambulatory care, including management of comorbidities and day care unit logistics, are discussed.Summary: Long-term follow-up of children exposed to general anesthesia before the age of 4 years has limited impact on academic achievement or cognitive performance and should not delay the treatment of common ENT pathology, which can impair speech and language development. A more liberal approach to fasting, employing a 6–4–0 regime allowing children fluids up until theater, may become an accepted practice in future. ED and EA should be discriminated from pain in recovery and, where the child is at risk of harm, should be treated promptly. Postoperative pain at home remains problematic in ambulatory surgery and better parental education is needed. Effective ambulatory care ultimately requires a well-coordinated team approach from effective preassessment to postoperative follow-up. Keywords: myringotomy, ventilation tubes, anesthesia, pediatrics, ambulatory, day case

  17. Cognitive assessment on elderly people under ambulatory care

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    Bruna Zortea

    2015-04-01

    Full Text Available Objective: to evaluate the cognitive state of elderly people under ambulatory care and investigating the connection between such cognitive state and sociodemographic variables, health conditions, number of and adhesion to medicine. Methods: transversal, exploratory, and descriptive study, with a quantitative approach, realized with 107 elderly people under ambulatory care in a university hospital in southern Brazil, in november, 2013. The following variables were used: gender, age, civil status, income, schooling, occupation, preexisting noncommunicable diseases, number and type of prescribed medications, adhesion, mini-mental state examination score, and cognitive status. Data was analyzed through inferential and descriptive statistics. Results: the prevalence of cognitive deficit was of 42.1% and had a statistically significant connection to schooling, income, civil status, hypertension, and cardiopathy. Conclusion: nurses can intervene to avoid the increase of cognitive deficit through an assessment of the elderly person, directed to facilitative strategies to soften this deficit.

  18. Health professionals' beliefs related to parental involvement in ambulatory care: an international inquiry.

    Science.gov (United States)

    Tourigny, Jocelyne; Chartrand, Julie; Massicotte, Julie

    2008-01-01

    Changes in health care delivery in Canada and Europe, especially the shift to ambulatory care, have modified the care that children and parents receive and have prompted the need for a partnership alliance. The objectives of this exploratory study were to identify Canadian and Belgian health professionals' beliefs and attitudes towards parental involvement in their child's ambulatory care and to determine if these beliefs varied according to cultural background. Health professionals from both countries generally were in favor of parental involvement in their child's care, but are uncertain about its advantages and disadvantages. Facilitators and barriers mentioned by the health care providers were related to parents' abilities or their attitudes toward partnership, and they also expressed a need for more education on the subject. Results of this study indicate that health professionals working in ambulatory care are not fully ready to utilize parents as true partners in their interventions with children and families. Staff education is an important step towards the establishment and maintenance of a real partnership.

  19. Wait watchers: the application of a waiting list active management program in ambulatory care.

    Science.gov (United States)

    de Belvis, Antonio Giulio; Marino, Marta; Avolio, Maria; Pelone, Ferruccio; Basso, Danila; Dei Tos, Gian Antonio; Cinquetti, Sandro; Ricciardi, Walter

    2013-04-01

    This study describes and evaluates the application of a waiting list management program in ambulatory care. Waiting list active management survey (telephone call and further contact); before and after controlled trial. Local Health Trust in Veneto Region (North-East of Italy) in 2008-09. Five hundred and one people on a 554 waiting list for C Class ambulatory care diagnostic and/or clinical investigations (electrocardiography plus cardiology ambulatory consultation, eye ambulatory consultation, carotid vessels Eco-color-Doppler, legs Eco-color-Doppler or colonoscopy, respectively). Active list management program consisting of a telephonic interview on 21 items to evaluate socioeconomic features, self-perceived health status, social support, referral physician, accessibility and patients' satisfaction. A controlled before-and-after study was performed to evaluate anonymously the overall impact on patients' self-perceived quality of care. The rate of patients with deteriorating healthcare conditions; rate of dropout; interviewed degree of satisfaction about the initiative; overall impact on citizens' perceived quality of care. 95.4% patients evaluated the initiative as useful. After the intervention, patients more likely to have been targeted with the program showed a statistically significant increase in self-reported quality of care. Positive impact of the program on some dimensions of ambulatory care quality (health status, satisfaction, willingness to remain in the queue), thus confirming the outstanding value of 'not to leave people alone' and 'not to leave them feeling themselves alone' in healthcare delivery.

  20. Adherence to a diabetic care plan provides better glycemic control in ambulatory patients with type 2 diabetes.

    Science.gov (United States)

    Chiu, Yi-Wen; Chang, Jer-Ming; Lin, Li-Ing; Chang, Pi-Yu; Lo, Wan-Ching; Wu, Ling-Chu; Chen, Tun-Chieh; Hwang, Shang-Jyh

    2009-04-01

    Tight control of blood sugar improves the outcomes for diabetic patients, but it can only be achieved by adhering to a well-organized care plan. To evaluate the effect of a diabetes care plan with reinforcement of glycemic control in diabetic patients, 98 ambulatory patients with type 2 diabetes who visited our diabetes clinic every 3-4 months and who completed four education courses given by certified diabetes educators within 3 months after the first visit, were defined as the Intervention group. A total of 82 patients fulfilling the inclusion criteria for the Intervention group but who missed at least half of the diabetes education sessions were selected as controls. Both groups had comparable mean hemoglobin A1c (HbA1c) levels at baseline, which decreased significantly at 3 months and were maintained at approximately constant levels at intervals for up to 1 year. The HbA1c decrement in the Intervention group was significantly greater than that in the Control group over the 1-year follow-up period (HbA1c change: -2.5 +/- 1.8% vs. -1.1 +/- 1.7%, p decrement occurred during the first 3 months, and accounted for 95.6% and 94.6% of the total HbA1c decrements in the Intervention and Control groups, respectively. In the multiple regression model, after adjustment for age, body mass index, and duration of diabetes, the Intervention group may still have a 12.6% improvement in HbA1c from their original value to the end of 1 year treatment compared with the Control group (p < 0.05). Diabetes care, with reinforcement from certified diabetes educators, significantly improved and maintained the effects on glycemic control in ambulatory patients with type 2 diabetes.

  1. Adherence to A Diabetic Care Plan Provides Better Glycemic Control in Ambulatory Patients With Type 2 Diabetes

    Directory of Open Access Journals (Sweden)

    Yi-Wen Chiu

    2009-04-01

    Full Text Available Tight control of blood sugar improves the outcomes for diabetic patients, but it can only be achieved by adhering to a well-organized care plan. To evaluate the effect of a diabetes care plan with reinforcement of glycemic control in diabetic patients, 98 ambulatory patients with type 2 diabetes who visited our diabetes clinic every 3–4 months and who completed four education courses given by certified diabetes educators within 3 months after the first visit, were defined as the Intervention group. A total of 82 patients fulfilling the inclusion criteria for the Intervention group but who missed at least half of the diabetes education sessions were selected as controls. Both groups had comparable mean hemoglobin A1c (HbA1c levels at baseline, which decreased significantly at 3 months and were maintained at approximately constant levels at intervals for up to 1 year. The HbA1c decrement in the Intervention group was significantly greater than that in the Control group over the 1-year follow-up period (HbA1c change: −2.5 ± 1.8% vs. −1.1 ± 1.7%, p < 0.01. The maximal HbA1c decrement occurred during the first 3 months, and accounted for 95.6% and 94.6% of the total HbA1c decrements in the Intervention and Control groups, respectively. In the multiple regression model, after adjustment for age, body mass index, and duration of diabetes, the Intervention group may still have a 12.6% improvement in HbA1c from their original value to the end of 1 year treatment compared with the Control group (p < 0.05. Diabetes care, with reinforcement from certified diabetes educators, significantly improved and maintained the effects on glycemic control in ambulatory patients with type 2 diabetes.

  2. Adopting Ambulatory Breast Cancer Surgery as the Standard of Care in an Asian Population

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    Yvonne Ying Ru Ng

    2014-01-01

    Full Text Available Introduction. Ambulatory surgery is not commonly practiced in Asia. A 23-hour ambulatory (AS23 service was implemented at our institute in March 2004 to allow more surgeries to be performed as ambulatory procedures. In this study, we reviewed the impact of the AS23 service on breast cancer surgeries and reviewed surgical outcomes, including postoperative complications, length of stay, and 30-day readmission. Methods. Retrospective review was performed of 1742 patients who underwent definitive breast cancer surgery from 1 March 2004 to 31 December 2010. Results. By 2010, more than 70% of surgeries were being performed as ambulatory procedures. Younger women (P<0.01, those undergoing wide local excision (P<0.01 and those with ductal carcinoma-in situ or early stage breast cancer (P<0.01, were more likely to undergo ambulatory surgery. Six percent of patients initially scheduled for ambulatory surgery were eventually managed as inpatients; a third of these were because of perioperative complications. Wound complications, 30-day readmission and reoperation rates were not more frequent with ambulatory surgery. Conclusion. Ambulatory breast cancer surgery is now the standard of care at our institute. An integrated workflow facilitating proper patient selection and structured postoperativee outpatient care have ensured minimal complications and high patient acceptance.

  3. Preparing for the primary care clinic: an ambulatory boot camp for internal medicine interns

    Science.gov (United States)

    Esch, Lindsay M.; Bird, Amber-Nicole; Oyler, Julie L.; Lee, Wei Wei; Shah, Sachin D.; Pincavage, Amber T.

    2015-01-01

    Introduction Internal medicine (IM) interns start continuity clinic with variable ambulatory training. Multiple other specialties have utilized a boot camp style curriculum to improve surgical and procedural skills, but boot camps have not been used to improve interns’ ambulatory knowledge and confidence. The authors implemented and assessed the impact of an intern ambulatory boot camp pilot on primary care knowledge, confidence, and curricular satisfaction. Methods During July 2014, IM interns attended ambulatory boot camp. It included clinically focused case-based didactic sessions on common ambulatory topics as well as orientation to the clinic and electronic medical records. Interns anonymously completed a 15-question pre-test on topics covered in the boot camp as well as an identical post-test after the boot camp. The interns were surveyed regarding their confidence and satisfaction. Results Thirty-eight interns participated in the boot camp. Prior to the boot camp, few interns reported confidence managing common outpatient conditions. The average pre-test knowledge score was 46.3%. The average post-test knowledge score significantly improved to 76.1% (pinterns reported that the boot camp was good preparation for clinics and 97% felt that the boot camp boosted their confidence. Conclusions The ambulatory boot camp pilot improved primary care knowledge, and interns thought it was good preparation for clinic. The ambulatory boot camp was well received and may be an effective way to improve the preparation of interns for primary care clinic. Further assessment of clinical performance and expansion to other programs and specialties should be considered. PMID:26609962

  4. Supply sensitive services in Swiss ambulatory care: An analysis of basic health insurance records for 2003-2007

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    Künzi Beat

    2010-11-01

    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

  5. Attitude of clinical faculty members in Shiraz Medical University towards private practice physicians' participation in ambulatory care education

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    Khatereh Mahori

    2002-04-01

    Full Text Available Background: Improvement of medical education is necessary for meeting health care demands. Participation of private practice physicians in ambulatory care training is an effective method for enhancing medical students' skills. Purpose This study was undertaken to determine clinical professors' views about participation of physicians with private office in ambulatory care training. Methods: Participants composed of 162 Shiraz Medical University faculty members from 12 disciplines. A questionnaire requesting faculty members' views on different aspects of ambulat01y care teaching and interaction of community-based organizations was distributed. Results: Of 120 (74.1% respondents, 64 (54.2% believed that clinical settings of medical university are appropriate for ambulatory care training. Private practice physicians believed more than academic physicians without private office that private offices have wider range of patients, more common cases, and better follow up chance; and is also a better setting for learning ambulatory care compared with medical university clinical centers. Overall, 32 (29.1% respondent’s found the participation of physicians with private practice on medical education positive. Key words medical education, ambulatory medicine, private practice

  6. Interspecialty communication supported by health information technology associated with lower hospitalization rates for ambulatory care-sensitive conditions.

    Science.gov (United States)

    O'Malley, Ann S; Reschovsky, James D; Saiontz-Martinez, Cynthia

    2015-01-01

    Practice tools such as health information technology (HIT) have the potential to support care processes, such as communication between health care providers, and influence care for "ambulatory care-sensitive conditions" (ACSCs). ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization. To date, associations between such primary care practice capabilities and hospitalizations for ambulatory care-sensitive conditions have been primarily limited to smaller, local studies or unique delivery systems rather than nationally representative studies of primary care physicians in the United States. We analyzed a nationally representative sample of 1,819 primary care physicians who responded to the Center for Studying Health System Change's Physician Survey. We linked 3 years of Medicare claims (2007 to 2009) with these primary care physician survey respondents. This linkage resulted in the identification of 123,760 beneficiaries with one or more of 4 ambulatory care-sensitive chronic conditions (diabetes, chronic obstructive pulmonary disease, asthma, and congestive heart failure) for whom these physicians served as the usual provider. Key independent variables of interest were physicians' practice capabilities, including communication with specialists, use of care managers, participation in quality and performance measurement, use of patient registries, and HIT use. The dependent variable was a summary measure of ambulatory care-sensitive hospitalizations for one or more of these 4 conditions. Higher provider-reported levels of communication between primary care and specialist physicians were associated with lower rates of potentially avoidable hospitalizations. While there was no significant main effect between HIT use and ACSC hospitalizations, the associations between interspecialty communication and ACSC hospitalizations were magnified in the presence of higher HIT use. For example, patients in practices with both the

  7. Electronic health record "super-users" and "under-users" in ambulatory care practices.

    Science.gov (United States)

    Rumball-Smith, Juliet; Shekelle, Paul; Damberg, Cheryl L

    2018-01-01

    This study explored variation in the extent of use of electronic health record (EHR)-based health information technology (IT) functionalities across US ambulatory care practices. Use of health IT functionalities in ambulatory care is important for delivering high-quality care, including that provided in coordination with multiple practitioners. We used data from the 2014 Healthcare Information and Management Systems Society Analytics survey. The responses of 30,123 ambulatory practices with an operational EHR were analyzed to examine the extent of use of EHR-based health IT functionalities for each practice. We created a novel framework for classifying ambulatory care practices employing 7 domains of health IT functionality. Drawing from the survey responses, we created a composite "use" variable indicating the extent of health IT functionality use across these domains. "Super-user" practices were defined as having near-full employment of the 7 domains of health IT functionalities and "under-users" as those with minimal or no use of health IT functionalities. We used multivariable logistic regression to investigate how the odds of super-use and under-use varied by practice size, type, urban or rural location, and geographic region. Seventy-three percent of practices were not using EHR technologies to their full capability, and nearly 40% were classified as under-users. Under-user practices were more likely to be of smaller size, situated in the West, and located outside a metropolitan area. To achieve the broader benefits of the EHR and health IT, health systems and policy makers need to identify and address barriers to full use of health IT functionalities.

  8. Improving outpatient access and patient experiences in academic ambulatory care.

    Science.gov (United States)

    O'Neill, Sarah; Calderon, Sherry; Casella, Joanne; Wood, Elizabeth; Carvelli-Sheehan, Jayne; Zeidel, Mark L

    2012-02-01

    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.

  9. [Face-lift surgery in ambulatory].

    Science.gov (United States)

    Soulhiard, F

    2017-10-01

    The proposal is to demonstrate that facelift surgery is particularly suitable for the care in ambulatory. Between 2010 and 2016, 246 patients were operated for a facelift in ambulatory. No major complication arose in this series (241). Among the patients, 98% expressed their satisfaction and would accept again this intervention in ambulatory. The facelift can be realized in ambulatory with complete safety. The rate of satisfaction shows a very strong support of the patients for the ambulatory care. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

  10. National ambulatory antibiotic prescribing patterns for pediatric urinary tract infection, 1998-2007.

    Science.gov (United States)

    Copp, Hillary L; Shapiro, Daniel J; Hersh, Adam L

    2011-06-01

    The goal of this study was to investigate patterns of ambulatory antibiotic use and to identify factors associated with broad-spectrum antibiotic prescribing for pediatric urinary tract infections (UTIs). We examined antibiotics prescribed for UTIs for children aged younger than 18 years from 1998 to 2007 using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Amoxicillin-clavulanate, quinolones, macrolides, and second- and third-generation cephalosporins were classified as broad-spectrum antibiotics. We evaluated trends in broad-spectrum antibiotic prescribing patterns and performed multivariable logistic regression to identify factors associated with broad-spectrum antibiotic use. Antibiotics were prescribed for 70% of pediatric UTI visits. Trimethoprim-sulfamethoxazole was the most commonly prescribed antibiotic (49% of visits). Broad-spectrum antibiotics were prescribed one third of the time. There was no increase in overall use of broad-spectrum antibiotics (P = .67); however, third-generation cephalosporin use doubled from 12% to 25% (P = .02). Children younger than 2 years old (odds ratio: 6.4 [95% confidence interval: 2.2-18.7, compared with children 13-17 years old]), females (odds ratio: 3.6 [95% confidence interval: 1.6-8.5]), and temperature ≥ 100.4°F (odds ratio: 2.9 [95% confidence interval: 1.0-8.6]) were independent predictors of broad-spectrum antibiotic prescribing. Race, physician specialty, region, and insurance status were not associated with antibiotic selection. Ambulatory care physicians commonly prescribe broad-spectrum antibiotics for the treatment of pediatric UTIs, especially for febrile infants in whom complicated infections are more likely. The doubling in use of third-generation cephalosporins suggests that opportunities exist to promote more judicious antibiotic prescribing because most pediatric UTIs are susceptible to narrower alternatives.

  11. Patients' need for more counseling on diet, exercise, and smoking cessation: results from the National Ambulatory Medical Care Survey.

    Science.gov (United States)

    Heaton, Pamela C; Frede, Stacey M

    2006-01-01

    To determine the percentage of physicians who reported counseling patients on diet/nutrition, exercise, weight reduction, or smoking cessation during their office visits when responding to the 2002 National Ambulatory Medical Care Survey (NAMCS). We sought to establish whether patients are receiving adequate counseling from physicians on the basis of this nationwide survey. Retrospective database analysis. United States. Data included 184,668,007 physician visits for patients diagnosed with type 2 diabetes, hyperlipidemia, hypertension, or obesity; 140,362,102 physician visits for patients in which insulin/oral antidiabetics, antihyperlipidemia drugs, angiotensin-converting enzyme inhibitors, thiazide diuretics, or weight loss drugs were prescribed; and 82,317,640 physician visits for patients who smoked or used tobacco. Not applicable. Frequency of responses for counseling/education/therapy about diet/nutrition, exercise, weight reduction, and tobacco use/exposure. For patients with type 2 diabetes, hyperlipidemia, or hypertension, or patients receiving a drug in one of the drug classes that may indicate the presence of these diseases, patients did not receive any type of diet or exercise counseling during more than one half of all visits. Visits by patients who were diagnosed as obese were most likely to receive any type of counseling (80.2%). Of visits for patients who used tobacco, 78.6% did not include any counseling about smoking cessation. Patients are insufficiently counseled and educated about the need for lifestyle changes that can affect their risks for common chronic diseases. As accessible and ideally positioned health care providers, pharmacists could potentially affect the rising epidemic of obesity and other lifestyle-related diseases by filling this void.

  12. Prescription of opioid and nonopioid analgesics for dental care in emergency departments: Findings from the National Hospital Ambulatory Medical Care Survey.

    Science.gov (United States)

    Okunseri, Christopher; Okunseri, Elaye; Xiang, Qun; Thorpe, Joshua M; Szabo, Aniko

    2014-01-01

    The aim of this study was to examine trends and associated factors in the prescription of opioid analgesics, nonopioid analgesics, opioid and nonopioid analgesic combinations, and no analgesics by emergency physicians for nontraumatic dental condition (NTDC)-related visits. Our secondary aim was to investigate whether race/ethnicity is a possible predictor of receiving a prescription for either type of medication for NTDC visits in emergency departments (EDs) after adjustment for potential covariates. We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997-2000 and 2003-2007, and used multinomial multivariate logistic regression to estimate the probability of receiving a prescription for opioid analgesics, nonopioid analgesics, or a combination of both, compared with receiving no analgesics for NTDC-related visits. During 1997-2000 and 2003-2007, prescription of opioid analgesics and combinations of opioid and nonopioid analgesics increased, and that of no analgesics decreased over time. The prescription rates for opioid analgesics, nonopioid analgesics, opioid and nonopioid analgesic combinations, and no analgesics for NTDC-related visits in EDs were 43 percent, 20 percent, 12 percent, and 25 percent, respectively. Majority of patients categorized as having severe pain received prescriptions for opioids for NTDC-related visits in EDs. After adjusting for covariates, patients with self-reported dental reasons for visit and severe pain had a significantly higher probability of receiving prescriptions for opioid analgesics and opioid and nonopioid analgesic combinations. Prescription of opioid analgesics increased over time. ED physicians were more likely to prescribe opioid analgesics and opioid and nonopioid analgesic combinations for NTDC-related visits with reported severe pain. © 2014 American Association of Public Health Dentistry.

  13. Health care restructuring and family physician care for those who died of cancer

    Directory of Open Access Journals (Sweden)

    Johnston Grace

    2005-01-01

    Full Text Available Abstract Background During the 1990s, health care restructuring in Nova Scotia resulted in downsized hospitals, reduced inpatient length of stay, capped physician incomes and restricted practice locations. Concurrently, the provincial homecare program was redeveloped and out-of-hospital cancer deaths increased from 20% (1992 to 30% (1998. These factors all pointed to a transfer of end-of-life inpatient hospital care to more community-based care. The purpose of this study was to describe the trends in the provision of Family Physician (FP visits to advanced cancer patients in Nova Scotia (NS during the years of health care restructuring. Methods Design Secondary multivariate analysis of linked population-based datafiles including the Queen Elizabeth II Health Sciences Centre Oncology Patient Information System (NS Cancer Registry, Vital Statistics, the NS Hospital Admissions/Separations file and the Medical Services Insurance Physician Services database. Setting Nova Scotia, an eastern Canadian province (population: 950,000. Subjects: All patients who died of lung, colorectal, breast or prostate cancer between April 1992 and March 1998 (N = 7,212. Outcome Measures Inpatient and ambulatory FP visits, ambulatory visits by location (office, home, long-term care facility, emergency department, time of day (regular hours, after hours, total length of inpatient hospital stay and number of hospital admissions during the last six months of life. Results In total, 139,641 visits were provided by family physicians: 15% of visits in the office, 10% in the home, 5% in the emergency department (ED, 5% in a long-term-care centre and 64% to hospital inpatients. There was no change in the rate of FP visits received for office, home and long-term care despite the fact that there were 13% fewer hospital admissions, and length of hospital stay declined by 21%. Age-sex adjusted estimates using negative binomial regression indicate a decline in hospital inpatient FP

  14. Ambulatory laparoscopic minor hepatic surgery: Retrospective observational study.

    Science.gov (United States)

    Gaillard, M; Tranchart, H; Lainas, P; Tzanis, D; Franco, D; Dagher, I

    2015-11-01

    Over the last decade, laparoscopic hepatic surgery (LHS) has been increasingly performed throughout the world. Meanwhile, ambulatory surgery has been developed and implemented with the aims of improving patient satisfaction and reducing health care costs. The objective of this study was to report our preliminary experience with ambulatory minimally invasive LHS. Between 1999 and 2014, 172 patients underwent LHS at our institution, including 151 liver resections and 21 fenestrations of hepatic cysts. The consecutive series of highly selected patients who underwent ambulatory LHS were included in this study. Twenty patients underwent ambulatory LHS. Indications were liver cysts in 10 cases, liver angioma in 3 cases, focal nodular hyperplasia in 3 cases, and colorectal hepatic metastasis in 4 cases. The median operative time was 92 minutes (range: 50-240 minutes). The median blood loss was 35 mL (range: 20-150 mL). There were no postoperative complications or re-hospitalizations. All patients were hospitalized after surgery in our ambulatory surgery unit, and were discharged 5-7 hours after surgery. The median postoperative pain score at the time of discharge was 3 (visual analogue scale: 0-10; range: 0-4). The median quality-of-life score at the first postoperative visit was 8 (range: 6-10) and the median cosmetic satisfaction score was 8 (range: 7-10). This series shows that, in selected patients, ambulatory LHS is feasible and safe for minor hepatic procedures. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

  15. The Ambulatory Integration of the Medical and Social (AIMS) model: A retrospective evaluation.

    Science.gov (United States)

    Rowe, Jeannine M; Rizzo, Victoria M; Shier Kricke, Gayle; Krajci, Kate; Rodriguez-Morales, Grisel; Newman, Michelle; Golden, Robyn

    2016-01-01

    An exploratory, retrospective evaluation of Ambulatory Integration of the Medical and Social (AIMS), a care coordination model designed to integrate medical and non-medical needs of patients and delivered exclusively by social workers was conducted to examine mean utilization of costly health care services for older adult patients. Results reveal mean utilization of 30-day hospital readmissions, emergency department (ED) visits, and hospital admissions are significantly lower for the study sample compared to the larger patient population. Comparisons with national population statistics reveal significantly lower mean utilization of 30-day admissions and ED visits for the study sample. The findings offer preliminary support regarding the value of AIMS.

  16. National Ambulatory Antibiotic Prescribing Patterns for Pediatric Urinary Tract Infection, 1998–2007

    Science.gov (United States)

    Shapiro, Daniel J.; Hersh, Adam L.

    2011-01-01

    OBJECTIVE: The goal of this study was to investigate patterns of ambulatory antibiotic use and to identify factors associated with broad-spectrum antibiotic prescribing for pediatric urinary tract infections (UTIs). METHODS: We examined antibiotics prescribed for UTIs for children aged younger than 18 years from 1998 to 2007 using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Amoxicillin-clavulanate, quinolones, macrolides, and second- and third-generation cephalosporins were classified as broad-spectrum antibiotics. We evaluated trends in broad-spectrum antibiotic prescribing patterns and performed multivariable logistic regression to identify factors associated with broad-spectrum antibiotic use. RESULTS: Antibiotics were prescribed for 70% of pediatric UTI visits. Trimethoprim-sulfamethoxazole was the most commonly prescribed antibiotic (49% of visits). Broad-spectrum antibiotics were prescribed one third of the time. There was no increase in overall use of broad-spectrum antibiotics (P = .67); however, third-generation cephalosporin use doubled from 12% to 25% (P = .02). Children younger than 2 years old (odds ratio: 6.4 [95% confidence interval: 2.2–18.7, compared with children 13–17 years old]), females (odds ratio: 3.6 [95% confidence interval: 1.6–8.5]), and temperature ≥100.4°F (odds ratio: 2.9 [95% confidence interval: 1.0–8.6]) were independent predictors of broad-spectrum antibiotic prescribing. Race, physician specialty, region, and insurance status were not associated with antibiotic selection. CONCLUSIONS: Ambulatory care physicians commonly prescribe broad-spectrum antibiotics for the treatment of pediatric UTIs, especially for febrile infants in whom complicated infections are more likely. The doubling in use of third-generation cephalosporins suggests that opportunities exist to promote more judicious antibiotic prescribing because most pediatric UTIs are susceptible to narrower

  17. The comprehensive care project: measuring physician performance in ambulatory practice.

    Science.gov (United States)

    Holmboe, Eric S; Weng, Weifeng; Arnold, Gerald K; Kaplan, Sherrie H; Normand, Sharon-Lise; Greenfield, Sheldon; Hood, Sarah; Lipner, Rebecca S

    2010-12-01

    To investigate the feasibility, reliability, and validity of comprehensively assessing physician-level performance in ambulatory practice. Ambulatory-based general internists in 13 states participated in the assessment. We assessed physician-level performance, adjusted for patient factors, on 46 individual measures, an overall composite measure, and composite measures for chronic, acute, and preventive care. Between- versus within-physician variation was quantified by intraclass correlation coefficients (ICC). External validity was assessed by correlating performance on a certification exam. Medical records for 236 physicians were audited for seven chronic and four acute care conditions, and six age- and gender-appropriate preventive services. Performance on the individual and composite measures varied substantially within (range 5-86 percent compliance on 46 measures) and between physicians (ICC range 0.12-0.88). Reliabilities for the composite measures were robust: 0.88 for chronic care and 0.87 for preventive services. Higher certification exam scores were associated with better performance on the overall (r = 0.19; pmeasures and by sampling feasible numbers of patients for each condition. © Health Research and Educational Trust.

  18. Anaesthesia for Ambulatory Paediatric Surgery: Common ...

    African Journals Online (AJOL)

    BACKGROUND: Ambulatory surgical care accounts for over 70% of elective procedures in Northern America. Ambulatory paediatric surgical practice is not widespread in Nigeria. This report examined clinical indicators for quality care in paediatric ambulatory surgery using common outcomes after day case procedures as ...

  19. Evolving health information technology and the timely availability of visit diagnoses from ambulatory visits: a natural experiment in an integrated delivery system.

    Science.gov (United States)

    Bardach, Naomi S; Huang, Jie; Brand, Richard; Hsu, John

    2009-07-17

    Health information technology (HIT) may improve health care quality and outcomes, in part by making information available in a timelier manner. However, there are few studies documenting the changes in timely availability of data with the use of a sophisticated electronic medical record (EMR), nor a description of how the timely availability of data might differ with different types of EMRs. We hypothesized that timely availability of data would improve with use of increasingly sophisticated forms of HIT. We used an historical observation design (2004-2006) using electronic data from office visits in an integrated delivery system with three types of HIT: Basic, Intermediate, and Advanced. We calculated the monthly percentage of visits using the various types of HIT for entry of visit diagnoses into the delivery system's electronic database, and the time between the visit and the availability of the visit diagnoses in the database. In January 2004, when only Basic HIT was available, 10% of office visits had diagnoses entered on the same day as the visit and 90% within a week; 85% of office visits used paper forms for recording visit diagnoses, 16% used Basic at that time. By December 2006, 95% of all office visits had diagnoses available on the same day as the visit, when 98% of office visits used some form of HIT for entry of visit diagnoses (Advanced HIT for 67% of visits). Use of HIT systems is associated with dramatic increases in the timely availability of diagnostic information, though the effects may vary by sophistication of HIT system. Timely clinical data are critical for real-time population surveillance, and valuable for routine clinical care.

  20. Time providing care outside visits in a home-based primary care program.

    Science.gov (United States)

    Pedowitz, Elizabeth J; Ornstein, Katherine A; Farber, Jeffrey; DeCherrie, Linda V

    2014-06-01

    To assess how much time physicians in a large home-based primary care (HBPC) program spend providing care outside of home visits. Unreimbursed time and patient and provider-related factors that may contribute to that time were considered. Mount Sinai Visiting Doctors (MSVD) providers filled out research forms for every interaction involving care provision outside of home visits. Data collected included length of interaction, mode, nature, and with whom the interaction was for 3 weeks. MSVD, an academic home-visit program in Manhattan, New York. All primary care physicians (PCPs) in MSVD (n = 14) agreed to participate. Time data were analyzed using a comprehensive estimate and conservative estimates to quantify unbillable time. Data on 1,151 interactions for 537 patients were collected. An average 8.2 h/wk was spent providing nonhome visit care for a full-time provider. Using the most conservative estimates, 3.6 h/wk was estimated to be unreimbursed per full-time provider. No significant differences in interaction times were found between patients with and without dementia, new and established patients, and primary-panel and covered patients. Home-based primary care providers spend substantial time providing care outside home visits, much of which goes unrecognized in the current reimbursement system. These findings may help guide practice development and creation of new payment systems for HBPC and similar models of care. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

  1. Application of frequent itemsets mining to analyze patterns of one-stop visits in Taiwan.

    Directory of Open Access Journals (Sweden)

    Chun-Yi Tu

    Full Text Available BACKGROUND: The free choice of health care facilities without limitations on frequency of visits within the National Health Insurance in Taiwan gives rise to not only a high number of annual ambulatory visits per capita but also a unique "one-stop shopping"phenomenon, which refers to a patient' visits to several specialties of the same healthcare facility in one day. The visits to multiple physicians would increase the potential risk of polypharmacy. The aim of this study was to analyze the frequency and patterns of one-stop visits in Taiwan. METHODOLOGY/PRINCIPAL FINDINGS: The claims datasets of 1 million nationally representative people within Taiwan's National Health Insurance in 2005 were used to calculate the number of patients with one-stop visits. The frequent itemsets mining was applied to compute the combination patterns of specialties in the one-stop visits. Among the total 13,682,469 ambulatory care visits in 2005, one-stop visits occurred 144,132 times and involved 296,822 visits (2.2% of all visits by 66,294 (6.6% persons. People tended to have this behavior with age and the percentage reached 27.5% (5,662 in 20,579 in the age group ≥80 years. In general, women were more likely to have one-stop visits than men (7.2% vs. 6.0%. Internal medicine plus ophthalmology was the most frequent combination with a visited frequency of 3,552 times (2.5%, followed by cardiology plus neurology with 3,183 times (2.2%. The most frequent three-specialty combination, cardiology plus neurology and gastroenterology, occurred only 111 times. CONCLUSIONS/SIGNIFICANCE: Without the novel computational technique, it would be hardly possible to analyze the extremely diverse combination patterns of specialties in one-stop visits. The results of the study could provide useful information either for the hospital manager to set up integrated services or for the policymaker to rebuild the health care system.

  2. Collaborative Care in Ambulatory Psychiatry: Content Analysis of Consultations to a Psychiatric Pharmacist

    Science.gov (United States)

    Gotlib, Dorothy; Bostwick, Jolene R.; Calip, Seema; Perelstein, Elizabeth; Kurlander, Jacob E.; Fluent, Thomas

    2017-01-01

    Objectives To determine the volume and nature (or topic) of consultations submitted to a psychiatric pharmacist embedded in an ambulatory psychiatry clinic, within a tertiary care academic medical center and to increase our understanding about the ways in which providers consult with an available psychiatric pharmacist. Experimental Design Authors analyze and describe the ambulatory psychiatric pharmacist consultation log at an academic ambulatory clinic. All consultation questions were submitted between July 2012 and October 2014. Principal Observations Psychiatry residents, attending physicians, and advanced practice nurse practitioners submitted 280 primary questions. The most common consultation questions from providers consulted were related to drug-drug interactions (n =70), drug formulations/dosing (n =48), adverse effects (n =43), and pharmacokinetics/lab monitoring/cross-tapering (n =36). Conclusions This is a preliminary analysis that provides information about how psychiatry residents, attending physicians, and advanced practice nurse practitioners at our health system utilize a psychiatric pharmacist. This collaborative relationship may have implications for the future of psychiatric care delivery. PMID:28936009

  3. Collaborative Care in Ambulatory Psychiatry: Content Analysis of Consultations to a Psychiatric Pharmacist.

    Science.gov (United States)

    Gotlib, Dorothy; Bostwick, Jolene R; Calip, Seema; Perelstein, Elizabeth; Kurlander, Jacob E; Fluent, Thomas

    2017-09-15

    To determine the volume and nature (or topic) of consultations submitted to a psychiatric pharmacist embedded in an ambulatory psychiatry clinic, within a tertiary care academic medical center and to increase our understanding about the ways in which providers consult with an available psychiatric pharmacist. Authors analyze and describe the ambulatory psychiatric pharmacist consultation log at an academic ambulatory clinic. All consultation questions were submitted between July 2012 and October 2014. Psychiatry residents, attending physicians, and advanced practice nurse practitioners submitted 280 primary questions. The most common consultation questions from providers consulted were related to drug-drug interactions (n =70), drug formulations/dosing (n =48), adverse effects (n =43), and pharmacokinetics/lab monitoring/cross-tapering (n =36). This is a preliminary analysis that provides information about how psychiatry residents, attending physicians, and advanced practice nurse practitioners at our health system utilize a psychiatric pharmacist. This collaborative relationship may have implications for the future of psychiatric care delivery.

  4. Evolving health information technology and the timely availability of visit diagnoses from ambulatory visits: A natural experiment in an integrated delivery system

    Directory of Open Access Journals (Sweden)

    Brand Richard

    2009-07-01

    Full Text Available Abstract Background Health information technology (HIT may improve health care quality and outcomes, in part by making information available in a timelier manner. However, there are few studies documenting the changes in timely availability of data with the use of a sophisticated electronic medical record (EMR, nor a description of how the timely availability of data might differ with different types of EMRs. We hypothesized that timely availability of data would improve with use of increasingly sophisticated forms of HIT. Methods We used an historical observation design (2004–2006 using electronic data from office visits in an integrated delivery system with three types of HIT: Basic, Intermediate, and Advanced. We calculated the monthly percentage of visits using the various types of HIT for entry of visit diagnoses into the delivery system's electronic database, and the time between the visit and the availability of the visit diagnoses in the database. Results In January 2004, when only Basic HIT was available, 10% of office visits had diagnoses entered on the same day as the visit and 90% within a week; 85% of office visits used paper forms for recording visit diagnoses, 16% used Basic at that time. By December 2006, 95% of all office visits had diagnoses available on the same day as the visit, when 98% of office visits used some form of HIT for entry of visit diagnoses (Advanced HIT for 67% of visits. Conclusion Use of HIT systems is associated with dramatic increases in the timely availability of diagnostic information, though the effects may vary by sophistication of HIT system. Timely clinical data are critical for real-time population surveillance, and valuable for routine clinical care.

  5. Costs of war: excess health care burdens during the wars in Afghanistan and Iraq (relative to the health care experience pre-war).

    Science.gov (United States)

    2012-11-01

    This report estimates the health care burden related to the wars in Iraq and Afghanistan by calculating the difference between the total health care delivered to U.S. military members during wartime (October 2001 to June 2012) and that which would have been delivered if pre-war (January 1998 to August 2001) rates of ambulatory visits, hospitalizations, and hospital bed days of active component members of the U.S. Armed Forces had persisted during the war. Overall, there were estimated excesses of 17,023,491 ambulatory visits, 66,768 hospitalizations, and 634,720 hospital bed days during the war period relative to that expected based on pre-war experience. Army and Marine Corps members and service members older than 30 accounted for the majority of excess medical care during the war period. The illness/injury-specific category of mental disorders was the single largest contributor to the total estimated excesses of ambulatory visits, hospitalizations, and bed days. The total health care burdens associated with the wars in Afghanistan and Iraq are undoubtedly greater than those enumerated in this report because this analysis did not address care delivered in deployment locations or at sea, care rendered by civilian providers to reserve component members in their home communities, care of veterans by the Departments of Defense and Veterans Affairs, preventive care for the sake of force health protection, and future health care associated with wartime injuries and illnesses.

  6. Infection Prevention and Control in Pediatric Ambulatory Settings.

    Science.gov (United States)

    Rathore, Mobeen H; Jackson, Mary Anne

    2017-11-01

    Since the American Academy of Pediatrics published its statement titled "Infection Prevention and Control in Pediatric Ambulatory Settings" in 2007, there have been significant changes that prompted this updated statement. Infection prevention and control is an integral part of pediatric practice in ambulatory medical settings as well as in hospitals. Infection prevention and control practices should begin at the time the ambulatory visit is scheduled. All health care personnel should be educated regarding the routes of transmission and techniques used to prevent the transmission of infectious agents. Policies for infection prevention and control should be written, readily available, updated every 2 years, and enforced. Many of the recommendations for infection control and prevention from the Centers for Disease Control and Prevention for hospitalized patients are also applicable in the ambulatory setting. These recommendations include requirements for pediatricians to take precautions to identify and protect employees likely to be exposed to blood or other potentially infectious materials while on the job. In addition to emphasizing the key principles of infection prevention and control in this policy, we update those that are relevant to the ambulatory care patient. These guidelines emphasize the role of hand hygiene and the implementation of diagnosis- and syndrome-specific isolation precautions, with the exemption of the use of gloves for routine diaper changes and wiping a well child's nose or tears for most patient encounters. Additional topics include respiratory hygiene and cough etiquette strategies for patients with a respiratory tract infection, including those relevant for special populations like patients with cystic fibrosis or those in short-term residential facilities; separation of infected, contagious children from uninfected children when feasible; safe handling and disposal of needles and other sharp medical devices; appropriate use of personal

  7. Virtual Visits in Home Health Care for Older Adults

    Directory of Open Access Journals (Sweden)

    Anne Marie Lunde Husebø

    2014-01-01

    Full Text Available Background. This review identifies the content of virtual visits in community nursing services to older adults and explores the manner in which service users and the nurses use virtual visits. Design. An integrative literature review. Method. Data collection comprised a literature search in three databases: Cinahl, Medline, and PubMed. In addition, a manual search of reference lists and expert consultation were performed. A total of 12 articles met the inclusion criteria. The articles were reviewed in terms of study characteristics, service content and utilization, and patient and health care provider experience. Results. Our review shows that in most studies the service is delivered on a daily basis and in combination with in-person visits. The findings suggest that older home-dwelling patients can benefit from virtual visits in terms of enhanced social inclusion and medication compliance. Service users and their nurses found virtual visits satisfactory and suitable for care delivery in home care to the elderly. Evidence for cost-saving benefits of virtual visits was not found. Conclusions. The findings can inform the planning of virtual visits in home health care as a complementary service to in-person visits, in order to meet the increasingly complex needs of older adults living at home.

  8. An elective course on current concepts in adult ambulatory care.

    Science.gov (United States)

    Vincent, Ashley H; Weber, Zachary A

    2014-12-15

    To design and evaluate a doctor of pharmacy course exploring disease states commonly encountered in ambulatory care, while applying literature to clinical practice and promoting a continual learning mindset. This elective incorporated a learner-centered teaching approach. Each week, 2 groups of students were assigned a clinical trial to present to their peers. The focus was on clinical application and impact, rather than literature evaluation. A social networking group on Facebook was used to expose students to pharmacy information outside the classroom. Student grades were determined by multiple activities: presentations, participation and moderation of the Facebook group, class participation, quiz scores, and quiz question development. Course evaluations served as a qualitative assessment of student learning and perceptions, quizzes were the most objective assessment of student learning, and presentation evaluations were the most directed assessment of course goals. This elective was an innovative approach to teaching ambulatory care that effectively filled a curricular void. Successful attainment of the primary course goals and objectives was demonstrated through course evaluations, surveys, and quiz and presentation scores.

  9. Clinical productivity of primary care nurse practitioners in ambulatory settings.

    Science.gov (United States)

    Xue, Ying; Tuttle, Jane

    Nurse practitioners are increasingly being integrated into primary care delivery to help meet the growing demand for primary care. It is therefore important to understand nurse practitioners' productivity in primary care practice. We examined nurse practitioners' clinical productivity in regard to number of patients seen per week, whether they had a patient panel, and patient panel size. We further investigated practice characteristics associated with their clinical productivity. We conducted cross-sectional analysis of the 2012 National Sample Survey of Nurse Practitioners. The sample included full-time primary care nurse practitioners in ambulatory settings. Multivariable survey regression analyses were performed to examine the relationship between practice characteristics and nurse practitioners' clinical productivity. Primary care nurse practitioners in ambulatory settings saw an average of 80 patients per week (95% confidence interval [CI]: 79-82), and 64% of them had their own patient panel. The average patient panel size was 567 (95% CI: 522-612). Nurse practitioners who had their own patient panel spent a similar percent of time on patient care and documentation as those who did not. However, those with a patient panel were more likely to provide a range of clinical services to most patients. Nurse practitioners' clinical productivity was associated with several modifiable practice characteristics such as practice autonomy and billing and payment policies. The estimated number of patients seen in a typical week by nurse practitioners is comparable to that by primary care physicians reported in the literature. However, they had a significantly smaller patient panel. Nurse practitioners' clinical productivity can be further improved. Copyright © 2016 Elsevier Inc. All rights reserved.

  10. Measuring adequacy of prenatal care: does missing visit information matter?

    Science.gov (United States)

    Kurtzman, Jordan H; Wasserman, Erin B; Suter, Barbara J; Glantz, J Christopher; Dozier, Ann M

    2014-09-01

    Kotelchuck's Adequacy of Prenatal Care Utilization (APNCU) Index is frequently used to classify levels of prenatal care. In the Finger Lakes Region (FLR) of upstate New York, prenatal care visit information late in pregnancy is often not documented on the birth certificate. We studied the extent of this missing information and its impact on the validity of regional APNCU scores. We calculated the "weeks between" a mother's last prenatal care visit and her infant's date of birth. We adjusted the APNCU algorithm creating the Last Visit Adequacy of Prenatal Care (LV-APNC) Index using the last recorded prenatal care visit date as the end point of care and the expected number of visits at that time. We compared maternal characteristics by care level with each index, examining rates of reclassification and number of "weeks between" by birth hospital. Stuart-Maxwell, McNemar, chi-square, and t-tests were used to determine statistical significance. Based on 58,462 births, the mean "weeks between" was 2.8 weeks. Compared with their APNCU Index score, 42.4 percent of mothers were reclassified using the LV-APNC Index. Major movement occurred from Intermediate (APNCU) to Adequate or Adequate Plus (LV-APNC) leaving the Intermediate Care group a more at-risk group of mothers. Those with Adequate or Adequate Plus Care (LV-APNC) increased by 31.6 percent, surpassing the Healthy People 2020 objective. In the FLR, missing visit information at the end of pregnancy results in an underestimation of mothers' prenatal care. Future research is needed to determine the extent of this missing visit information on the national level. © 2014 Wiley Periodicals, Inc.

  11. Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study

    Science.gov (United States)

    Nathan, Lisa M.; Shi, Quihu; Plewniak, Kari; Zhang, Charles; Nsabimana, Damien; Sklar, Marc; Mutimura, Eugene; Merkatz, Irwin R.; Einstein, Mark H.; Anastos, Kathryn

    2015-01-01

    To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB (p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB. PMID:25652061

  12. Emergency service: a strategy for hospital-sponsored ambulatory care satellites.

    Science.gov (United States)

    Gregory, D; Klegon, D; Steinhauer, B

    1984-01-01

    This analysis of the overall market position of free-standing emergency care was based on a telephone survey of 300 randomly chosen households in a southeastern metropolitan area. Results show that consumer preferences for cost and convenience create a strong market for free-standing emergency facilities. Emergicare centers are in an ideal situation to capture the market for acute and minor emergency care. To be worthwhile, the emergency room in a more comprehensive ambulatory care facility should serve as a feeder of new patients and be profitable in its own right. However, free-standing emergency facilities must not only attract patients through convenience and price, but they must also maintain patients through assuring quality care and satisfaction.

  13. Home care, hospitalizations and doctor visits

    OpenAIRE

    Gonçalves Judite; Weaver France

    2014-01-01

    This study estimates the effects of formal home care on hospitalizations and doctor visits. We compare the effects of medically- and non-medically-related home care and investigate heterogeneous effects by age group and informal care availability. Two-part models are estimated, using data from Switzerland. In this federal country, home care policy is decentralized into cantons (i.e. states). The endogeneity of home care is addressed by using instrumental variables, canton and time fixed effec...

  14. Antenatal care visits and pregnancy outcomes at a Kenyan rural ...

    African Journals Online (AJOL)

    Background: The goal of antenatal care (ANC) is to improve maternal and neonatal outcomes. Fewer ANC visits in focused antenatal care (FANC) model can affect maternal and perinatal outcomes in low income settings where the number ANC visits are often low. Objective: To determine the number of ANC visits and their ...

  15. Palliative care team visits. Qualitative study through participant observation.

    Science.gov (United States)

    Alfaya Góngora, Maria Del Mar; Bueno Pernias, Maria José; Hueso Montoro, César; Guardia Mancilla, Plácido; Montoya Juárez, Rafael; García Caro, Maria Paz

    2016-03-30

    To describe the clinical encounters that occur when a palliative care team provides patient care and the features that influence these encounters and indicate whether they are favorable or unfavorable depending on the expectations and feelings of the various participants. A qualitative case study conducted via participant observation. A total of 12 observations of the meetings of palliative care teams with patients and families in different settings (home, hospital and consultation room) were performed. The visits were follow-up or first visits, either scheduled or on demand. Content analysis of the observation was performed. The analysis showed the normal follow-up activity of the palliative care unit that was focused on controlling symptoms, sharing information and providing advice on therapeutic regimens and care. The environment appeared to condition the patients' expressions and the type of patient relationship. Favorable clinical encounter conditions included kindness and gratitude. Unfavorable conditions were deterioration caused by approaching death, unrealistic family objectives and limited resources. Home visits from basic palliative care teams play an important role in patient and family well-being. The visits seem to focus on controlling symptoms and are conditioned by available resources.

  16. Prenatal Care: First Trimester Visits

    Science.gov (United States)

    ... care provider will discuss the importance of proper nutrition and prenatal vitamins. Your first prenatal visit is a good time to discuss exercise, sex during pregnancy and other lifestyle issues. You might also discuss your work environment and the use of medications during pregnancy. If ...

  17. Innovation in survivor care: group visits.

    Science.gov (United States)

    Trotter, Kathryn; Frazier, Alana; Hendricks, Colleen K; Scarsella, Heidi

    2011-04-01

    The Centering Cancer Survivorship (CCS) follow-up care program is an innovation in healthcare delivery that meets the needs of cancer survivors and cancer centers. Piloted in a breast cancer clinic, the program provides an avenue for provision of psychological support and health-promotion activities, as well as surveillance for recurrence or late effects. The program empowers each survivor by enlisting her to produce a written breast cancer survivorship care plan for personal use and to share with her primary care provider. Concurrently, this innovation should enhance the viability of the primary cancer center by freeing appointment slots for oncologists who provide expensive therapies to newly diagnosed patients. The CCS program's central feature is the implementation of a multidisciplinary clinic designated specifically for breast cancer survivors in which follow-up care is provided through a group visit medical model. This model of care provides opportunities for health assessment, patient empowerment, and patient education within a framework of social support from peers with similar issues. The group visit model may be well suited to addressing the unique chronic healthcare needs of breast cancer survivors. Further evaluation is needed to verify cost-benefit analysis.

  18. Measuring interdependence in ambulatory care.

    Science.gov (United States)

    Katerndahl, David; Wood, Robert; Jaen, Carlos R

    2017-04-01

    Complex systems differ from complicated systems in that they are nonlinear, unpredictable and lacking clear cause-and-effect relationships, largely due to the interdependence of their components (effects of interconnectedness on system behaviour and consequences). The purpose of this study was to demonstrate the potential for network density to serve as a measure of interdependence, assess its concurrent validity and test whether the use of valued or binary ties yields better results. This secondary analysis used the 2010 National Ambulatory Care Medical Survey to assess interdependence of 'top 20' diagnoses seen and medications prescribed for 14 specialties. The degree of interdependence was measured as the level of association between diagnoses and drug interactions among medications. Both valued and binary network densities were computed for each specialty. To assess concurrent validity, these measures were correlated with previously-derived valid measures of complexity of care using the same database, adjusting for diagnosis and medication diversity. Partial correlations between diagnosis density, and both diagnosis and total input complexity, were significant, as were those between medication density and both medication and total output complexity; for both diagnosis and medication densities, adjusted correlations were higher for binary rather than valued densities. This study demonstrated the feasibility and validity of using network density as a measure of interdependence. When adjusted for measure diversity, density-complexity correlations were significant and higher for binary than valued density. This approach complements other methods of estimating complexity of care and may be applicable to unique settings. © 2015 John Wiley & Sons, Ltd.

  19. Factors affecting subspecialty referrals by pediatric primary care providers for children with obesity-related comorbidities.

    Science.gov (United States)

    Walsh, Carolyn O; Milliren, Carly E; Feldman, Henry A; Taveras, Elsie M

    2013-08-01

    To determine referral patterns from pediatric primary care to subspecialists for overweight/obesity and related comorbidities. We used the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to identify overweight/obesity and 5 related comorbidities in primary care visits between 2005 and 2009 by children 6 to 18 years. The primary outcome was whether the visit ended in referral. We used multivariable analysis to examine factors associated with referral. We identified 34,225 database visits. A total of 17.1% were with overweight (body mass index=85th to 94th percentile) or obese (body mass index≥95th percentile) patients. A total of 7.1% of primary care visits with overweight/obese children ended in referral. Referral was more likely when obesity was the reason for visit (odds ratio=2.83; 95% confidence interval=1.61-4.97) but was not associated with presence of a comorbidity (odds ratio=1.35; 95% confidence interval=0.75-2.44). Most overweight or obese children are not referred, regardless of comorbidity status. One reason may be low levels of appropriate diagnosis.

  20. The Cardiovascular Health in Ambulatory Care Research Team performance indicators for the primary prevention of cardiovascular disease: a modified Delphi panel study.

    Science.gov (United States)

    Tu, Jack V; Maclagan, Laura C; Ko, Dennis T; Atzema, Clare L; Booth, Gillian L; Johnston, Sharon; Tu, Karen; Lee, Douglas S; Bierman, Arlene; Hall, Ruth; Bhatia, R Sacha; Gershon, Andrea S; Tobe, Sheldon W; Sanmartin, Claudia; Liu, Peter; Chu, Anna

    2017-04-25

    High-quality ambulatory care can reduce cardiovascular disease risk, but important gaps exist in the provision of cardiovascular preventive care. We sought to develop a set of key performance indicators that can be used to measure and improve cardiovascular care in the primary care setting. As part of the Cardiovascular Health in Ambulatory Care Research Team initiative, we established a 14-member multidisciplinary expert panel to develop a set of indicators for measuring primary prevention performance in ambulatory cardiovascular care. We used a 2-stage modified Delphi panel process to rate potential indicators, which were identified from the literature and national cardiovascular organizations. The top-rated indicators were pilot tested to determine their measurement feasibility with the use of data routinely collected in the Canadian health care system. A set of 28 indicators of primary prevention performance were identified, which were grouped into 5 domains: risk factor prevalence, screening, management, intermediate outcomes and long-term outcomes. The indicators reflect the major cardiovascular risk factors including smoking, obesity, hypertension, diabetes, dyslipidemia and atrial fibrillation. All indicators were determined to be amenable to measurement with the use of population-based administrative (physician claims, hospital admission, laboratory, medication), survey or electronic medical record databases. The Cardiovascular Health in Ambulatory Care Research Team indicators of primary prevention performance provide a framework for the measurement of cardiovascular primary prevention efforts in Canada. The indicators may be used by clinicians, researchers and policy-makers interested in measuring and improving the prevention of cardiovascular disease in ambulatory care settings. Copyright 2017, Joule Inc. or its licensors.

  1. Mental Health-related Physician Office Visits by Adults Aged 18 and Over: United States, 2012-2014.

    Science.gov (United States)

    Cherry, Donald; Albert, Michael; McCaig, Linda F

    2018-06-01

    In 2016, mental illness affected about 45 million U.S. adults (1). Although mental health-related office visits are often made to psychiatrists (2), primary care physicians can serve as the main source of treatment for patients with mental health issues (3); however, availability of provider type may vary by geographic region (3,4). This report uses data from the 2012-2014 National Ambulatory Medical Care Survey (NAMCS) to examine adult mental healthrelated physician office visits by specialty and selected patient characteristics. All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

  2. Record of hospitalizations for ambulatory care sensitive conditions: validation of the hospital information system.

    Science.gov (United States)

    Rehem, Tania Cristina Morais Santa Barbara; de Oliveira, Maria Regina Fernandes; Ciosak, Suely Itsuko; Egry, Emiko Yoshikawa

    2013-01-01

    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. 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. 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. 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.

  3. Record of hospitalizations for ambulatory care sensitive conditions: validation of the hospital information system

    Directory of Open Access Journals (Sweden)

    Tania Cristina Morais Santa Barbara Rehem

    2013-09-01

    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.

  4. Practitioner Gender and Quality of Care in Ambulatory Cardiology Practices: A Report From the National Cardiovascular Data Practice Innovation and Clinical Excellence (PINNACLE) Registry.

    Science.gov (United States)

    Gupta, Dipti; Tang, Fengming; Masoudi, Frederick A; Jones, Philip G; Chan, Paul S; Daugherty, Stacie L

    Some studies suggest that female practitioners are more likely to provide guideline-concordant care than male practitioners; however, little is known about the role of practitioner gender in cardiology. The aim of the study was to measure the association between practitioner gender and adherence to the cardiovascular performance measures in the American College of Cardiology's ambulatory Practice Innovation and Clinical Excellence Registry. Patients with at least 1 outpatient visit with a unique practitioner were included. Among eligible patients, adherence to 7 guideline-supported performance measures for coronary artery disease, heart failure, and atrial fibrillation over 12 months after registry entry was compared by practitioner gender using hierarchical models adjusting for practitioner type (physicians vs advance practice practitioners) and number of visits. The study cohort included 1493 individual practitioners who saw 769 139 patients; 80% of practitioners were men. Male practitioners were more often physicians compared with female practitioners (98.2% vs 43.7%, P < .01). Accounting for practitioner category and visit frequency, guideline adherence rates were similar by practitioner gender for all measures with the exception of marginally higher rates for coronary artery disease performance measures for male practitioners compared with female practitioners (antiplatelet: rate ratio [RR] = 1.06; 95% confidence interval [CI], 1.03-1.09; β-blockers: RR = 1.06; 95% CI, 1.01-1.10; and lipid-lowering drug: RR = 1.07; 95% CI, 1.04-1.10) and atrial fibrillation (oral anticoagulants: RR = 1.05; 95% CI, 1.01-1.09). Male practitioners marginally outperformed their female counterparts in ambulatory practices enrolled in a voluntary cardiovascular performance improvement registry program. Overall low adherence to some performance measures suggests room for improvement among all practitioners.

  5. Does clinical exposure matter? Pilot assessment of patient visits in an urban family medicine residency program.

    Science.gov (United States)

    Iglar, Karl; Murdoch, Stuart; Meaney, Christopher; Krueger, Paul

    2018-01-01

    To determine the number of patient visits, patient demographic information, and diagnoses in an urban ambulatory care setting in a family medicine residency program, and assess the correlation between the number of patient visits and residents' in-training examination (ITE) scores. Retrospective analysis of data from resident practice profiles, electronic medical records, and residents' final ITE scores. Family medicine teaching unit in a community hospital in Barrie, Ont. Practice profile data were from family medicine residents enrolled in the program from July 1, 2013, to June 30, 2014, and electronic medical record and ITE data were from those enrolled in the program from July 1, 2010, to June 30, 2015. Number of patient visits, patient characteristics (eg, sex, age), priority topics addressed in clinic, resident characteristics (eg, age, sex, level of residency), and residents' final ITE scores. Between July 1, 2013, and June 30, 2014, there were 11 115 patient visits. First-year residents had a mean of 5.48 patient visits per clinic, and second-year residents had a mean of 5.98 patient visits per clinic. A Pearson correlation coefficient of 0.68 was found to exist between the number of patients seen and the final ITE scores, with a 10.5% difference in mean score between residents who had 1251 or more visits and those who had 1150 or fewer visits. Three diagnoses (ie, epistaxis, meningitis, and neck pain) deemed important for Certification by the College of Family Physicians of Canada were not seen by any of the residents in clinic. There is a moderate correlation between the number of patients seen by residents in ambulatory care and ITE scores in family medicine. It is important to assess patients' demographic information and diagnoses made in resident practices to ensure an adequate clinical experience. Copyright© the College of Family Physicians of Canada.

  6. Physician Networks and Ambulatory Care-sensitive Admissions.

    Science.gov (United States)

    Casalino, Lawrence P; Pesko, Michael F; Ryan, Andrew M; Nyweide, David J; Iwashyna, Theodore J; Sun, Xuming; Mendelsohn, Jayme; Moody, James

    2015-06-01

    Research on the quality and cost of care traditionally focuses on individual physicians or medical groups. Social network theory suggests that the care a patient receives also depends on the network of physicians with whom a patient's physician is connected. The objectives of the study are: (1) identify physician networks; (2) determine whether the rate of ambulatory care-sensitive hospital admissions (ACSAs) varies across networks--even different networks at the same hospital; and (3) determine the relationship between ACSA rates and network characteristics. We identified networks by applying network detection algorithms to Medicare 2008 claims for 987,000 beneficiaries in 5 states. We estimated a fixed-effects model to determine the relationship between networks and ACSAs and a multivariable model to determine the relationship between network characteristics and ACSAs. We identified 417 networks. Mean size: 129 physicians; range, 26-963. In the fixed-effects model, ACSA rates varied significantly across networks: there was a 46% difference in rates between networks at the 25th and 75th performance percentiles. At 95% of hospitals with admissions from 2 networks, the networks had significantly different ACSA rates; the mean difference was 36% of the mean ACSA rate. Networks with a higher percentage of primary-care physicians and networks in which patients received care from a larger number of physicians had higher ACSA rates. Physician networks have a relationship with ACSAs that is independent of the physicians in the network. Physician networks could be an important focus for understanding variations in medical care and for intervening to improve care.

  7. Access to Transportation and Health Care Visits for Medicaid Enrollees With Diabetes.

    Science.gov (United States)

    Thomas, Leela V; Wedel, Kenneth R; Christopher, Jan E

    2018-03-01

    Diabetes is a chronic condition that requires frequent health care visits for its management. Individuals without nonemergency medical transportation often miss appointments and do not receive optimal care. This study aims to evaluate the association between Medicaid-provided nonemergency medical transportation and diabetes care visits. A retrospective analysis was conducted of demographic and claims data obtained from the Oklahoma Medicaid program. Participants consisted of Medicaid enrollees with diabetes who made at least 1 visit for diabetes care in a year. The sample was predominantly female and white, with an average age of 46.38 years. Two zero-truncated Poisson regression models were estimated to assess the independent effect of transportation use on number of diabetes care visits. Use of nonemergency medical transportation is a significant predictor of diabetes care visits. Zero-truncated Poisson regression coefficients showed a positive association between the use of transportation and number of visits (0.6563, P urban; women made fewer visits than men (-0.09312; P transportation to Medicaid populations with diabetes, particularly in the rural areas where the prevalence of diabetes and complications are higher and the availability of medical resources lower than in the urban areas. © 2017 National Rural Health Association.

  8. Administrative Costs Associated With Physician Billing and Insurance-Related Activities at an Academic Health Care System.

    Science.gov (United States)

    Tseng, Phillip; Kaplan, Robert S; Richman, Barak D; Shah, Mahek A; Schulman, Kevin A

    2018-02-20

    Administrative costs in the US health care system are an important component of total health care spending, and a substantial proportion of these costs are attributable to billing and insurance-related activities. To examine and estimate the administrative costs associated with physician billing activities in a large academic health care system with a certified electronic health record system. This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system's total cost of processing an insurance claim. Estimated time required to perform billing and insurance-related activities, based on interviews with management personnel and physicians. Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures. Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of

  9. The financial and health burden of diabetic ambulatory care sensitive hospitalisations in Mexico

    OpenAIRE

    Lugo-Palacios, David G; Cairns, John

    2016-01-01

    Objective. To estimate the financial and health burden of diabetic ambulatory care sensitive hospitalisations (ACSH) in Mexico during 2001-2011. Materials and methods. We identified ACSH due to diabetic complications in general hospitals run by local health ministries and estimated their financial cost using diagnostic related groups. The health burden estimation assumes that patients would not have experienced complications if they had received appropriate primary care and computes the assoc...

  10. Patient characteristics associated with hospitalisations for ambulatory care sensitive conditions in Victoria, Australia

    Directory of Open Access Journals (Sweden)

    Ansari Zahid

    2012-12-01

    Full Text Available Abstract Background Ambulatory Care Sensitive Conditions (ACSCs are those for which hospitalisation is thought to be avoidable with the application of preventive care and early disease management, usually delivered in a primary care setting. ACSCs are used extensively as indicators of accessibility and effectiveness of primary health care. We examined the association between patient characteristics and hospitalisation for ACSCs in the adult and paediatric population in Victoria, Australia, 2003/04. Methods Hospital admissions data were merged with two area-level socioeconomic indexes: Index of Socio-Economic Disadvantage (IRSED and Accessibility/Remoteness Index of Australia (ARIA. Univariate and multiple logistic regressions were performed for both adult (age 18+ years and paediatric (age Results Predictors were much more strongly associated with ACSCs admissions compared to non-ACSCs admissions in the adult group than for the paediatric group with the exception of rurality. Significant adjusted ORs in the adult group were 1.06, 1.15, 1.13, 1.06 and 1.11 for sex, rurality, age, IRSED and ARIA variables, and 1.34, 1.04 and 1.09 in the paediatric group for rurality, IRSED and ARIA, respectively. Conclusions Disadvantaged paediatric and adult population experience more need of hospital care for ACSCs. Access barriers to primary care are plausible causes for the observed disparities. Understanding the characteristics of individuals experiencing access barriers to primary care will be useful for developing targeted interventions meeting the unique ambulatory needs of the population.

  11. [Management of alcohol use disorders in ambulatory care: Which follow-up and for how long?].

    Science.gov (United States)

    Benyamina, A; Reynaud, M

    2016-02-01

    Alcohol consumption with its addictive potential may lead to physical and psychological dependence as well as systemic toxicity all of which have serious detrimental health outcomes in terms of morbimortality. Despite the harmful potential of alcohol use disorders, the disease is often not properly managed, especially in ambulatory care. Psychiatric and general practitioners in ambulatory care are first in line to detect and manage patients with excessive alcohol consumption. However, this is still often regarded as an acute medical condition and its management is generally considered only over the short-term. On the contrary, alcohol dependence has been defined as a primary chronic disease of the brain reward, motivation, memory and related circuitry, involving the signalling pathway of neurotransmitters such as dopamine, opioid peptides, and gamma-aminobutyric acid. Thus, it should be regarded in terms of long-term management as are other chronic diseases. To propose a standard pathway for the management of alcohol dependence in ambulatory care in terms of duration of treatment and follow-up. Given the lack of official recommendations from health authorities which may help ambulatory care physicians in long-term management of patients with alcohol dependence, we performed a review and analysis of the most recent literature regarding the long-term management of other chronic diseases (diabetes, bipolar disorders, and depression) drawing a parallel with alcohol dependence. Alcohol dependence shares many characteristics with other chronic diseases, including a prolonged duration, intermittent acute and chronic exacerbations, and need for prolonged and often-lifelong care. In all cases, this requires sustained psychosocial changes from the patient. Patient motivation is also a major issue and should always be taken into consideration by psychiatric and general practitioners in ambulatory care. In chronic diseases, such as diabetes, bipolar disorders, or depression

  12. Performance of internal medicine residents in the primary interpretation of musculoskeletal radiographs in an ambulatory care setting

    International Nuclear Information System (INIS)

    Mann, F.A.; Stewart, N.R.; Terrell, C.B.

    1990-01-01

    This paper determines the characteristics of misinterpretations of musculoskeletal radiographs by internal medicine residents (IMRs) in an ambulatory care setting. Discordances between IMRs and staff radiologists were prospectively identified and retrospectively reviewed to assess type of error and patient outcome. The setting was an acute ambulatory care clinic at a large university hospital staffed by board-certified emergency medicine faculty and IMRs. Of 541 patients radiographed, 321 (59%) had adequate follow-up to establish outcome. Error characteristics examined included nature and site, type (false negative ([F-] or false positive [F+]), clinical significance, interpreter responsible, and level of interpreter training

  13. Ambulatory care of children treated with anticonvulsants - pitfalls after discharge from hospital.

    Science.gov (United States)

    Bertsche, A; Dahse, A-J; Neininger, M P; Bernhard, M K; Syrbe, S; Frontini, R; Kiess, W; Merkenschlager, A; Bertsche, T

    2013-09-01

    Anticonvulsants require special consideration particularly at the interface from hospital to ambulatory care. Observational study for 6 months with prospectively enrolled consecutive patients in a neuropediatric ward of a university hospital (age 0-anticonvulsant. Assessment of outpatient prescriptions after discharge. Parent interviews for emergency treatment for acute seizures and safety precautions. We identified changes of the brand in 19/82 (23%) patients caused by hospital's discharge letters (4/82; 5%) or in ambulatory care (15/82; 18%). In 37/76 (49%) of patients who were deemed to require rescue medication, no recommendation for such a medication was included in the discharge letters. 17/76 (22%) of the respective parents stated that they had no immediate access to rescue medication. Safety precautions were applicable in 44 epilepsy patients. We identified knowledge deficits in 27/44 (61%) of parents. Switching of brands after discharge was frequent. In the discharge letters, rescue medications were insufficiently recommended. Additionally, parents frequently displayed knowledge deficits in risk management. © Georg Thieme Verlag KG Stuttgart · New York.

  14. Patterns and Predictors of Depression Treatment among Older Adults with Parkinson’s Disease and Depression in Ambulatory Care Settings in the United States

    Directory of Open Access Journals (Sweden)

    Sandipan Bhattacharjee

    2018-01-01

    Full Text Available Little is known regarding depression treatment patterns and predictors among older adults with comorbid Parkinson's disease and depression (dPD in the United States (US. The objective of this study was to assess the patterns and predictors of depression treatment among older adults with dPD in the US. We adopted a cross-sectional study design by pooling multiple-year data (2005–2011 from the National Ambulatory Medical Care Survey (NAMCS and the outpatient department of the National Hospital Ambulatory Medical Care Survey (NHAMCS. The final study sample consisted of visits by older adults with dPD. Depression treatment was defined as antidepressant use with or without psychotherapy. To identify predictors of depression treatment, multivariate logistic regression analysis was conducted adjusting for predisposing, enabling, and need factors. Individuals with dPD and polypharmacy were 74% more likely to receive depression treatment (odds ratio = 1.743, 95% CI 1.376–2.209, while dPD subjects with comorbid chronic conditions were 44% less likely (odds ratio = 0.559, 95% CI 0.396–0.790 to receive depression treatment. Approximately six out of ten older adults with PD and depression received depression treatment. Treatment options for dPD are underutilized in routine clinical practice, and further research should explore how overall medical complexity presents a barrier to depression treatment.

  15. Clinical and economic outcomes of nurse-led services in the ambulatory care setting: A systematic review.

    Science.gov (United States)

    Chan, Raymond J; Marx, Wolfgang; Bradford, Natalie; Gordon, Louisa; Bonner, Ann; Douglas, Clint; Schmalkuche, Diana; Yates, Patsy

    2018-02-21

    With the increasing burden of chronic and age-related diseases, and the rapidly increasing number of patients receiving ambulatory or outpatient-based care, nurse-led services have been suggested as one solution to manage increasing demand on the health system as they aim to reduce waiting times, resources, and costs while maintaining patient safety and enhancing satisfaction. The aims of this review were to assess the clinical effectiveness, economic outcomes and key implementation characteristics of nurse-led services in the ambulatory care setting. A systematic review was conducted using the standard Cochrane Collaboration methodology and was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE EBSCO, CINAHL EBSCO, and PsycINFO Ovid (from inception to April 2016). Data were extracted and appraisal undertaken. We included randomised controlled trials; quasi-randomised controlled trials; controlled and non-controlled before-and-after studies that compared the effects of nurse-led services in the ambulatory or community care setting with an alternative model of care or standard care. Twenty-five studies of 180,308 participants were included in this review. Of the 16 studies that measured and reported on health-related quality of life outcomes, the majority of studies (n = 13) reported equivocal outcomes; with three studies demonstrating superior outcomes and one demonstrating inferior outcomes in comparison with physician-led and standard care. Nurse-led care demonstrated either equivalent or better outcomes for a number of outcomes including symptom burden, self-management and behavioural outcomes, disease-specific indicators, satisfaction and perception of quality of life, and health service use. Benefits of nurse-led services remain inconclusive in terms of economic outcomes. Nurse

  16. Characteristics of Emergency Department Visits by Older Versus Younger Homeless Adults in the United States

    Science.gov (United States)

    Steinman, Michael A.

    2013-01-01

    Objectives. We compared the characteristics of emergency department (ED) visits of older versus younger homeless adults. Methods. We analyzed 2005–2009 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of visits to hospitals and EDs, and used sampling weights, strata, and clustering variables to obtain nationally representative estimates. Results. The ED visits of homeless adults aged 50 years and older accounted for 36% of annual visits by homeless patients. Although demographic characteristics of ED visits were similar in older and younger homeless adults, clinical and health services characteristics differed. Older homeless adults had fewer discharge diagnoses related to psychiatric conditions (10% vs 20%; P = .002) and drug abuse (7% vs 15%; P = .003) but more diagnoses related to alcohol abuse (31% vs 23%; P = .03) and were more likely to arrive by ambulance (48% vs 36%; P = .02) and to be admitted to the hospital (20% vs 11%; P = .003). Conclusions. Older homeless adults’ patterns of ED care differ from those of younger homeless adults. Health care systems need to account for these differences to meet the needs of the aging homeless population. PMID:23597348

  17. Integrating Palliative Care Services in Ambulatory Oncology: An Application of the Edmonton Symptom Assessment System.

    Science.gov (United States)

    Rauenzahn, Sherri L; Schmidt, Susanne; Aduba, Ifeoma O; Jones, Jessica T; Ali, Nazneen; Tenner, Laura L

    2017-04-01

    Research in palliative care demonstrates improvements in overall survival, quality of life, symptom management, and reductions in the cost of care. Despite the American Society of Clinical Oncology recommendation for early concurrent palliative care in patients with advanced cancer and high symptom burden, integrating palliative services is challenging. Our aims were to quantitatively describe the palliative referral rates and symptom burden in a South Texas cancer center and establish a palliative referral system by implementing the Edmonton Symptom Assessment Scale (ESAS). As part of our Plan-Do-Study-Act process, all staff received an educational overview of the ESAS tool and consultation ordering process. The ESAS form was then implemented across five ambulatory oncology clinics to assess symptom burden and changes therein longitudinally. Referral rates and symptom assessment scores were tracked as metrics for quality improvement. On average, one patient per month was referred before implementation of the intervention compared with 10 patients per month after implementation across all clinics. In five sample clinics, 607 patients completed the initial assessment, and 430 follow-up forms were collected over 5 months, resulting in a total of 1,037 scores collected in REDCap. The mean ESAS score for initial patient visits was 20.0 (standard deviation, 18.1), and referred patients had an initial mean score of 39.0 (standard deviation, 19.0). This project highlights the low palliative care consultation rate, high symptom burden of oncology patients, and underuse of services by oncologists despite improvements with the introduction of a symptom assessment form and referral system.

  18. Verbal communication among Alzheimer's disease patients, their caregivers, and primary care physicians during primary care office visits.

    Science.gov (United States)

    Schmidt, Karen L; Lingler, Jennifer H; Schulz, Richard

    2009-11-01

    Primary care visits of patients with Alzheimer's disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual's verbal participation in these triadic interactions. To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty-three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed. PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver's own verbal participation. Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less. Encouraging verbal participation by AD patients and their caregivers may increase the AD patient's active role and caregiver satisfaction with primary care visits.

  19. [Role of Visiting Nursing Care in Japanese Home Healthcare].

    Science.gov (United States)

    Yu, Sang-Ju

    2018-02-01

    Taiwan's rapidly aging society is expected to make it a super-aged society in 2026. By 2060, people aged 65 or older will account for 40% of the population, a ratio that will approximate that in Japan. In Japan, the elderly population was 27.3% in 2016. By 2025, when the baby-boomers become 75 years old in Japan, issues of long-term care and end-of-life care will be more important and challenging. Since 1976, more Japanese have died in hospital settings than in home settings. Although the percentage of people dying at home increased slightly to 12.7% in 2016, after the recent introduction and promotion of home healthcare, Japan will face a significant challenge to deal with the healthcare 'tsunami' of high natural death rates, which is expected to impose a heavy death burdened on society by 2040, when the death rate is expected to reach 1,670,000/year. Therefore, the Japanese authorities have begun to promote the Community-based Integrated Care System, in which home healthcare and visiting nursing play crucial roles. This article summarizes the historical trend and current situation of visiting nursing in Japan. Japan uses a hybrid payment system for visiting nursing that is financially supported both through private medical insurance policies and Kaigo insurance (Japanese long-term care insurance). The total of 8613 visiting nursing stations that were active in community settings in 2016 cooperated with 14,000 support clinics for home healthcare and cared for 570,000 patients in home settings. We believe that visiting nursing will play an important role in home healthcare in Taiwan in the future.

  20. Visitation in the intensive care unit: impact on infection prevention and control.

    Science.gov (United States)

    Adams, Sheila; Herrera, Amando; Miller, Laura; Soto, Rhonda

    2011-01-01

    Evidence-based practice has shown that open visitation in the intensive care setting positively impacts patient outcomes. However, many intensive care units continue to strictly limit visitation hours. One concern for nurses is that open visitation will expose their vulnerable patients to an increased risk of infection. This fear is unfounded in professional literature as well as in the experience of a busy intensive care unit in San Antonio, Texas. Keeping our patients safe from hospital-acquired infections requires vigilant attention to infection prevention procedures. Meanwhile, what may actually be bugging our patients is a health care culture that is based on tradition and is blind to the many benefits provided by a more liberal visitation policy rooted in patient-centered care.

  1. A 5-year comparison of ED visits by homeless and nonhomeless patients.

    Science.gov (United States)

    Tadros, Allison; Layman, Shelley M; Brewer, Marissa Pantaleone; Davis, Stephen M

    2016-05-01

    A 2005 study examined emergency department (ED) utilization by homeless patients in the United States. Within the following 5 years, unemployment increased by 5%. The objective was to analyze changes in ED utilization between 2005 and 2010 by homeless patients and compare with nonhomeless visits. Data from the 2010 National Hospital Ambulatory Medical Care Survey were evaluated. Approximately 679854 visits were made by homeless patients, the majority of which were made by men (72.3%) and patients between the ages of 45 and 64 (50.5%). Homeless patients were twice as likely to be uninsured. ED visits by homeless patients had increased by 44% during the 5-year period. Arrival to the ED by ambulance increased by 14% between the study years, and homeless patients were less likely to be admitted. The number of visits by homeless patients in the ED increased proportionally to an overall increase in ED visits between 2005 and 2010. Copyright © 2016 Elsevier Inc. All rights reserved.

  2. Diagnosis of state visits to patients held in intensive care units

    Directory of Open Access Journals (Sweden)

    Rosa Del Socorro Morales-Aguila

    2017-01-01

    Full Text Available The visit is the space where it is possible to relate the patient, family and health personnel. To diagnose the situation of the visits to patients imprisoned in units of intensive care of Institutions Prestadoras of Health (IPS. Study descriptive, cross; the population was five intensive care units, the intrinsic sample consisted of 34 participants. respondents agreed visiting hours morning and afternoon 53%; the residence time of family members during the half-hour visit was 30%; the number of people allowed is three relatives 70%; information about the patient's progress is provided by the medical specialist 65%; 18% weakness was evident in the application of informed consent procedures make. These results serve to generate changes in the future with the attention paid to the families of critically ill patients, based on the recommendations of the American Association of Intensive Care more flexible patient visits focused on family relationship, in order to minimize anxiety produced by the gravity of their situation and environment of the Unit of Intensive care.

  3. [Hospitalizations for ambulatory care-sensitive conditions: validation study at a Hospital Information System (SIH) in the Federal District, Brazil, in 2012].

    Science.gov (United States)

    Cavalcante, Danyelle Monteiro; de Oliveira, Maria Regina Fernandes; Rehem, Tânia Cristina Morais Santa Bárbara

    2016-03-01

    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.

  4. Electronic medical records and efficiency and productivity during office visits.

    Science.gov (United States)

    Furukawa, Michael F

    2011-04-01

    To estimate the relationship between electronic medical record (EMR) use and efficiency of utilization and provider productivity during visits to US office-based physicians. Cross-sectional analysis of the 2006-2007 National Ambulatory Medical Care Survey. The sample included 62,710 patient visits to 2625 physicians. EMR systems included demographics, clinical notes, prescription orders, and laboratory and imaging results. Efficiency was measured as utilization of examinations, laboratory tests, radiology procedures, health education, nonmedication treatments, and medications. Productivity was measured as total services provided per 20-minute period. Survey-weighted regressions estimated association of EMR use with services provided, visit intensity/duration, and productivity. Marginal effects were estimated by averaging across all visits and by major reason for visit. EMR use was associated with higher probability of any examination (7.7%, 95% confidence interval [CI] = 2.4%, 13.1%); any laboratory test (5.7%, 95% CI = 2.6%, 8.8%); any health education (4.9%, 95% CI = 0.2%, 9.6%); and fewer laboratory tests (-7.1%, 95% CI = -14.2%, -0.1%). During pre/post surgery visits, EMR use was associated with 7.3% (95% CI= -12.9%, -1.8%) fewer radiology procedures. EMR use was not associated with utilization of nonmedication treatments and medications, or visit duration. During routine visits for a chronic problem, EMR use was associated with 11.2% (95% CI = 5.7%, 16.8%) more diagnostic/screening services provided per 20-minute period. EMR use had a mixed association with efficiency and productivity during office visits. EMRs may improve provider productivity, especially during visits for a new problem and routine chronic care.

  5. Automated conversation system before pediatric primary care visits: a randomized trial.

    Science.gov (United States)

    Adams, William G; Phillips, Barrett D; Bacic, Janine D; Walsh, Kathleen E; Shanahan, Christopher W; Paasche-Orlow, Michael K

    2014-09-01

    Interactive voice response systems integrated with electronic health records have the potential to improve primary care by engaging parents outside clinical settings via spoken language. The objective of this study was to determine whether use of an interactive voice response system, the Personal Health Partner (PHP), before routine health care maintenance visits could improve the quality of primary care visits and be well accepted by parents and clinicians. English-speaking parents of children aged 4 months to 11 years called PHP before routine visits and were randomly assigned to groups by the system at the time of the call. Parents' spoken responses were used to provide tailored counseling and support goal setting for the upcoming visit. Data were transferred to the electronic health records for review during visits. The study occurred in an urban hospital-based pediatric primary care center. Participants were called after the visit to assess (1) comprehensiveness of screening and counseling, (2) assessment of medications and their management, and (3) parent and clinician satisfaction. PHP was able to identify and counsel in multiple areas. A total of 9.7% of parents responded to the mailed invitation. Intervention parents were more likely to report discussing important issues such as depression (42.6% vs 25.4%; P PHP improved the quality of their care. Systems like PHP have the potential to improve clinical screening, counseling, and medication management. Copyright © 2014 by the American Academy of Pediatrics.

  6. Effect of the delegation of GP-home visits on the development of the number of patients in an ambulatory healthcare centre in Germany

    Science.gov (United States)

    2012-01-01

    Background The AGnES-concept (AGnES: GP-supporting, community-based, e-health-assisted, systemic intervention) was developed to support general practitioners (GPs) in undersupplied regions. The project aims to delegate GP-home visits to qualified AGnES-practice assistants, to increase the number of patients for whom medical care can be provided. This paper focuses on the effect of delegating GP-home visits on the total number of patients treated. First, the theoretical number of additional patients treated by delegating home visits to AGnES-practice assistants was calculated. Second, actual changes in the number of patients in participating GP-practices were analyzed. Methods The calculation of the theoretical increase in the number of patients was based on project data, data which were provided by the Association of Statutory Health Insurance Physicians, or which came from the literature. Setting of the project was an ambulatory healthcare centre in the rural county Oberspreewald-Lausitz in the Federal State of Brandenburg, which employed six GPs, four of which participated in the AGnES project. The analysis of changes in the number of patients in the participating GP-practices was based on the practices’ reimbursement data. Results The calculated mean capacity of AGnES-practice assistants was 1376.5 home visits/year. GPs perform on average 1200 home visits/year. Since home visits with an urgent medical reason cannot be delegated, we included only half the capacity of the AGnES-practice assistants in the analysis (corresponding to a 20 hour-work week). Considering all parameters in the calculation model, 360.1 GP-working hours/year can be saved. These GP-hours could be used to treat 170 additional patients/quarter year. In the four participating GP-practices the number of patients increased on average by 133 patients/quarter year during the project period, which corresponds to 78% of the theoretically possible number of patients. Conclusions The empirical

  7. Effect of the delegation of GP-home visits on the development of the number of patients in an ambulatory healthcare centre in Germany

    Directory of Open Access Journals (Sweden)

    van den Berg Neeltje

    2012-10-01

    Full Text Available Abstract Background The AGnES-concept (AGnES: GP-supporting, community-based, e-health-assisted, systemic intervention was developed to support general practitioners (GPs in undersupplied regions. The project aims to delegate GP-home visits to qualified AGnES-practice assistants, to increase the number of patients for whom medical care can be provided. This paper focuses on the effect of delegating GP-home visits on the total number of patients treated. First, the theoretical number of additional patients treated by delegating home visits to AGnES-practice assistants was calculated. Second, actual changes in the number of patients in participating GP-practices were analyzed. Methods The calculation of the theoretical increase in the number of patients was based on project data, data which were provided by the Association of Statutory Health Insurance Physicians, or which came from the literature. Setting of the project was an ambulatory healthcare centre in the rural county Oberspreewald-Lausitz in the Federal State of Brandenburg, which employed six GPs, four of which participated in the AGnES project. The analysis of changes in the number of patients in the participating GP-practices was based on the practices’ reimbursement data. Results The calculated mean capacity of AGnES-practice assistants was 1376.5 home visits/year. GPs perform on average 1200 home visits/year. Since home visits with an urgent medical reason cannot be delegated, we included only half the capacity of the AGnES-practice assistants in the analysis (corresponding to a 20 hour-work week. Considering all parameters in the calculation model, 360.1 GP-working hours/year can be saved. These GP-hours could be used to treat 170 additional patients/quarter year. In the four participating GP-practices the number of patients increased on average by 133 patients/quarter year during the project period, which corresponds to 78% of the theoretically possible number of patients

  8. Practices Caring For The Underserved Are Less Likely To Adopt Medicare's Annual Wellness Visit.

    Science.gov (United States)

    Ganguli, Ishani; Souza, Jeffrey; McWilliams, J Michael; Mehrotra, Ateev

    2018-02-01

    In 2011 Medicare introduced the annual wellness visit to help address the health risks of aging adults. The visit also offers primary care practices an opportunity to generate revenue, and may allow practices in accountable care organizations to attract healthier patients while stabilizing patient-practitioner assignments. However, uptake of the visit has been uneven. Using national Medicare data for the period 2008-15, we assessed practices' ability and motivation to adopt the visit. In 2015, 51.2 percent of practices provided no annual wellness visits (nonadopters), while 23.1 percent provided visits to at least a quarter of their eligible beneficiaries (adopters). Adopters replaced problem-based visits with annual wellness visits and saw increases in primary care revenue. Compared to nonadopters, adopters had more stable patient assignment and a slightly healthier patient mix. At the same time, visit rates were lower among practices caring for underserved populations (for example, racial minorities and those dually enrolled in Medicaid), potentially worsening disparities. Policy makers should consider ways to encourage uptake of the visit or other mechanisms to promote preventive care in underserved populations and the practices that serve them.

  9. PS1-10: How Can the Same Practice Be Classified as Having 2 and 900 MDs? NAMCS Data Collection in a Changing Ambulatory Care Environment

    Science.gov (United States)

    Halley, Meghan; Gillespie, Katherine; Rendle, Katharine; Luft, Harold

    2014-01-01

    Background/Aims Since 1973, the National Ambulatory Medical Care Survey (NAMCS), administered by the National Center for Health Statistics (NCHS) has been widely used in studies of ambulatory care. With the growth in large multispecialty practices – including many members of the HMORN – there is a need to understand how NAMCS data are collected and whether current processes yield accurate and reliable data. NAMCS collects data from physicians about their practices and abstracts a sample of patient visit records. This study reports on the physician component. Methods In collaboration with NCHS, nine physicians were randomly sampled from a multispecialty clinic using standard NAMCS recruitment procedures; eight physicians were eligible and agreed to participate. Using their standard protocols, three Field Representatives (FRs) conducted NAMCS physician interviews while a trained ethnographer (MH, KR) observed and audio-recorded each interview. Transcripts and field notes were analyzed using a grounded theory approach to identify key themes. Results Data have been collected and analyzed. They are currently undergoing standard confidentiality review by NCHS. However, this process has been delayed due to the government shutdown. We fully anticipate that results will be released in time for presentation at the HMORN conference. Conclusions Though we are precluded from disseminating results at this time, we will provide a full report of our results in our HMORN conference presentation.

  10. Providing value in ambulatory anesthesia.

    Science.gov (United States)

    Fosnot, Caroline D; Fleisher, Lee A; Keogh, John

    2015-12-01

    The purpose of this review is to discuss current practices and changes in the field of ambulatory anesthesia, in both hospital and ambulatory surgery center settings. New trends in ambulatory settings are discussed and a review of the most current and comprehensive guidelines for the care of ambulatory patients with comorbid conditions such as postoperative nausea and vomiting (PONV), obstructive sleep apnea and diabetes mellitus are reviewed. Future direction and challenges to the field are highlighted. Ambulatory anesthesia continues to be in high demand for many reasons; patients and surgeons want their surgical procedures to be swift, involve minimal postoperative pain, have a transient recovery time, and avoid an admission to the hospital. Factors that have made this possible for patients are improved surgical equipment, volatile anesthetic improvement, ultrasound-guided regional techniques, non-narcotic adjuncts for pain control, and the minimization of PONV. The decrease in time spent in a hospital also decreases the risk of wound infection, minimizes missed days from work, and is a socioeconomically favorable model, when possible. Recently proposed strategies which will allow surgeons and anesthesiologists to continue to meet the growing demand for a majority of surgical cases being same-day include pharmacotherapies with less undesirable side-effects, integration of ultrasound-guided regional techniques, and preoperative evaluations in appropriate candidates via a telephone call the night prior to surgery. Multidisciplinary communication amongst caregivers continues to make ambulatory settings efficient, safe, and socioeconomically favorable.It is also important to note the future impact that healthcare reform will have specifically on ambulatory anesthesia. The enactment of the Patient Protection and Affordable Care Act of 2010 will allow 32 million more people to gain access to preventive services that will require anesthesia such as screening

  11. Respiratory tract infection is the major cause of the ambulatory visits in children

    Directory of Open Access Journals (Sweden)

    Lue KoHuang

    2011-09-01

    Full Text Available Abstract Background As children represent the future, ensuring that they receive proper health care should be a primary concern of our societies. Epidemiological research underpins the importance of effective child health care strategies, and highlights the need for accurate data collection; such surveys are currently lacking in Taiwan. In our descriptive studies, we compared the differences of the ten most common diseases in the year 2000 and 2009 among Taiwanese children. Methods Data for a total of 174,651 and 142,200 visits under eighteen years old were collected from the National Health Insurance Research Database in year 2000 and 2009. A maximum of three outpatient diagnostic codes (the International Classification of Disease [ICD], ninth revision could be listed for every visit. Data were categorized according to the principal diagnoses, age and different specialties of physicians. Results Respiratory tract infection was the most common disease (58.21% to 44.77%. Teeth (4.90% to 5.16% and eye (2.52% to 3.15% problems were the also in the list of top ten diseases. In year 2009, the rate of allergic rhinitis was 2.87% in 7-18 years old group. Pediatricians were the first option for consultation, followed by ear, nose and throat specialists and family physicians. However, for the school age children group, the role of pediatricians with regards to children's health care showed a decrease in its importance. Conclusions The amount of information relevant to child health care is rapidly expanding. The ten most common diseases of the present analysis may serve as baseline data for future evaluations of the changes of type of diseases among children.

  12. Nurse-led case management for ambulatory complex patients in general health care: A systematic review

    NARCIS (Netherlands)

    Latour-Delfgaauw, C.H.M.; van der Windt, D.A.W.M.; de Jonge, P.; Riphagen, II; Vos, R.; Huyse, F.J.; Stalman, W.A.B.

    2007-01-01

    Objective: The aim of this study was to summarize the available literature on the effectiveness of ambulatory nurse-led case management for complex patients in general health care. Method: We searched MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and Cinahl. We included randomized

  13. Ambulatory anesthetic care in children undergoing myringotomy and tube placement: current perspectives

    OpenAIRE

    Robinson H; Engelhardt T

    2017-01-01

    Hal Robinson, Thomas Engelhardt Department of Anaesthesia, Royal Aberdeen Children’s Hospital, Aberdeen, UK Purpose: Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT) surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction.Recent findings: This review summarizes recently published studies about the long-term effects of g...

  14. Verbal Communication among Alzheimer’s Disease Patients, their Caregivers, and Primary Care Physicians during Primary Care Office Visits

    Science.gov (United States)

    Schmidt, Karen L.; Lingler, Jennifer H.; Schulz, Richard

    2009-01-01

    Objective Primary care visits of patients with Alzheimer’s disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual’s verbal participation in these triadic interactions. Methods To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed. Results PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver’s own verbal participation. Conclusion Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less. Practice Implications Encouraging verbal participation by AD patients and their caregivers may increase the AD patient’s active role and caregiver satisfaction with primary care visits. PMID:19395224

  15. The association between home care visits and same-day emergency department use: a case-crossover study.

    Science.gov (United States)

    Jones, Aaron; Schumacher, Connie; Bronskill, Susan E; Campitelli, Michael A; Poss, Jeffrey W; Seow, Hsien; Costa, Andrew P

    2018-04-30

    The extent to which home care visits contribute to the delay or avoidance of emergency department use is poorly characterized. We examined the association between home care visits and same-day emergency department use among patients receiving publicly funded home care. We conducted a population-based case-crossover study among patients receiving publicly funded home care in the Hamilton-Niagara-Haldimand-Brant region of Ontario between January and December 2015. Within individuals, all days with emergency department visits after 5 pm were selected as cases and matched with control days from the previous week. The cohort was stratified according to whether patients had ongoing home care needs ("long stay") or short-term home care needs ("short stay"). We used conditional logistical regression to estimate the association between receiving a home care visit during the day and visiting the emergency department after 5 pm on the same day. A total of 4429 long-stay patients contributed 5893 emergency department visits, and 2836 short-stay patients contributed 3476 visits. Receiving a home care nursing visit was associated with an increased likelihood of visiting the emergency department after 5 pm on the same day in both long-stay (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.17-1.48) and short-stay patients (OR 1.22, 95% CI 1.07-1.39). Stronger associations were observed for less acute visits to the emergency department. No associations were observed for other types of home care visits. Patients receiving home care were more likely to visit the emergency department during the evening on days they received a nursing visit. The mechanism of the association between home care visits and same-day emergency department use and the extent to which same-day emergency department visits could be prevented or diverted require additional investigation. © 2018 Joule Inc. or its licensors.

  16. Factors associated with end-of-life by home-visit nursing-care providers in Japan.

    Science.gov (United States)

    Nakanishi, Miharu; Niimura, Junko; Nishida, Atsushi

    2017-06-01

    Home-visit nursing-care services in Japan are expected to provide home hospice services for older patients with non-cancer diseases. The aim of the present study was to examine factors that contribute to the provision of end-of-life care by home-visit nursing-care providers in Japan. The present retrospective study was carried out using nationally representative cross-sectional data from the 2007, 2010, and 2013 Survey of Institutions and Establishments for Long-Term Care. A total of 138 008 randomly sampled home-visit nursing-care service users were included in this analysis. End-of-life care (study outcome) was defined as the provision of nursing-care within the last month of life. Of the 138 008 patients at home, 2280 (1.7%) received home-based nursing care within the last month of life, and end-of-life care was offered primarily to cancer patients (n = 1651; 72.4%). After accounting for patient characteristics, patients were more likely to receive end-of-life care when they used home-visit nursing-care providers that had a greater number of nursing staff or were located in a region with fewer hospital beds. Among home-visit nursing-care providers, the nursing staff ratio and the availability of hospital beds were related to the provision of end-of-life care. Home-visit nursing-care providers should establish specialist hospice care teams with enhanced staffing ratios to allow for the adequate provision of home-based end-of-life care. A community-based network between home-visit nursing-care providers and hospitals should also be established to attain an integrated end-of-life care system for elderly populations in regions with more hospital beds. Geriatr Gerontol Int 2017; 17: 991-998. © 2016 Japan Geriatrics Society.

  17. Patient Satisfaction with Collection of Patient-Reported Outcome Measures in Routine Care.

    Science.gov (United States)

    Recinos, Pablo F; Dunphy, Cheryl J; Thompson, Nicolas; Schuschu, Jesse; Urchek, John L; Katzan, Irene L

    2017-02-01

    Systematic collection of patient-reported outcome measures (PROMs) during ambulatory clinic visits can enhance communication between patient and provider, and provide the ability to evaluate outcomes of care. Little is known about patient satisfaction of PROM data collection in routine clinical care. To evaluate patient reaction to the routine collection of PROMs in the ambulatory setting. Before all ambulatory clinic visits at our neurological institute, patients electronically complete health status questionnaires. We administered an 8-question patient satisfaction survey to a sample of patients seen across the institute after their clinical visit. Of 343 patients approached, 323 agreed to participate. The majority responded that the questionnaire system was easy to use, was an appropriate length, and benefited their care overall (strongly agree or agree = 92.3%, 87.6%, and 77.3%, respectively). Provider review of the PROMs with the patient during the clinic visit was associated with significantly higher positive responses to all questions, even those regarding logistical aspects of the collection process. There were significant age and race differences in response to perceived benefit: those in the Black/other race category had a markedly lower probability of viewing the process favorably with increasing age. Systematic collection of PROMs via an electronic questionnaire appears to be well accepted by patients. A minority of patients did not feel the questionnaire content applied to their appointment or that the system was a beneficial feature of the clinical practice. The provider can significantly improve the patient's perception of PROM collection and the patient-physician encounter by reviewing the questionnaire results with the patient.

  18. Medication-related problem type and appearance rate in ambulatory hemodialysis patients

    Directory of Open Access Journals (Sweden)

    Drayer Debra K

    2003-12-01

    Full Text Available Abstract Background Hemodialysis (HD patients are at risk for medication-related problems (MRP. The MRP number, type, and appearance rate over time in ambulatory HD patients has not been investigated. Methods Randomly selected HD patients were enrolled to receive monthly pharmaceutical care visits. At each visit, MRP were identified through review of the patient chart, electronic medical record, patient interview, and communications with other healthcare disciplines. All MRP were categorized by type and medication class. MRP appearance rate was determined as the number of MRP identified per month/number of months in study. The number of MRP per patient-drug exposures were determined using: {[(number of patients × (mean number of medications]/(number of months of study} /number of MRP identified. Results were expressed as mean ± standard deviation or percentages. Results Patients were 62.6 ± 15.9 years old, had 6.4 ± 2.0 comorbid conditions, were taking 12.5 ± 4.2 medications, and 15.7 ± 7.2 doses per day at baseline. Medication-dosing problems (33.5%, adverse drug reactions (20.7%, and an indication that was not currently being treated (13.5% were the most common MRP. 5,373 medication orders were reviewed and a MRP was identified every 15.2 medication exposures. Overall MRP appearance rate was 0.68 ± 0.46 per patient per month. Conclusion MRP continue to occur at a high rate in ambulatory HD patients. Healthcare providers taking care of HD patients should be aware of this problem and efforts to avoid or resolve MRP should be undertaken at all HD clinics.

  19. Antenatal care visits' absenteeism at a secondary care medical facility in Southwest Nigeria.

    Science.gov (United States)

    Oloko, Olakunle; Ogunbode, Olayinka Oladunjoye; Roberts, Olumuyiwa; Arowojolu, Ayodele Olatunji

    2016-11-01

    Antenatal care (ANC) is a specialised pattern of care organised for pregnant women with the goal of maintaining good health and promoting safe delivery of healthy infants. It is an indispensable part of effective maternity care services. This study identified the factors responsible for absenteeism from ANC follow-up visits. It was a hospital-based prospective cross-sectional descriptive study conducted at a faith based secondary healthcare facility in Ibadan, Nigeria. Relevant data were retrieved using interviewer-administered structured questionnaires and antenatal health record cards. The major reasons identified for absenteeism were delay in receiving hospital services due to long queues at service points and understaffing. The pregnant women aged 35 years and above were the most likely to miss the visits. Therefore, there is the need for hospital administrators and health care givers to make the services patient-friendly.

  20. Optimizing anesthesia techniques in the ambulatory setting

    NARCIS (Netherlands)

    E. Galvin (Eilish)

    2007-01-01

    textabstractAmbulatory surgery refers to the process of admitting patients, administering anesthesia and surgical care, and discharging patients home following an appropriate level of recovery on the same day. The word ambulatory is derived from the latin word ambulare, which means ''to walk''. This

  1. An efficient and effective teaching model for ambulatory education.

    Science.gov (United States)

    Regan-Smith, Martha; Young, William W; Keller, Adam M

    2002-07-01

    Teaching and learning in the ambulatory setting have been described as inefficient, variable, and unpredictable. A model of ambulatory teaching that was piloted in three settings (1973-1981 in a university-affiliated outpatient clinic in Portland, Oregon, 1996-2000 in a community outpatient clinic, and 2000-2001 in an outpatient clinic serving Dartmouth Medical School's teaching hospital) that combines a system of education and a system of patient care is presented. Fully integrating learners into the office practice using creative scheduling, pre-rotation learning, and learner competence certification enabled the learners to provide care in roles traditionally fulfilled by physicians and nurses. Practice redesign made learners active members of the patient care team by involving them in such tasks as patient intake, histories and physicals, patient education, and monitoring of patient progress between visits. So that learners can be active members of the patient care team on the first day of clinic, pre-training is provided by the clerkship or residency so that they are able to competently provide care in the time available. To assure effective education, teaching and learning times are explicitly scheduled by parallel booking of patients for the learner and the preceptor at the same time. In the pilot settings this teaching model maintained or improved preceptor productivity and on-time efficiency compared with these outcomes of traditional scheduling. The time spent alone with patients, in direct observation by preceptors, and for scheduled case discussion was appreciated by learners. Increased satisfaction was enjoyed by learners, teachers, clinic staff, and patients. Barriers to implementation include too few examining rooms, inability to manipulate patient appointment schedules, and learners' not being present in a teaching clinic all the time.

  2. Recent trends in prescribing antibiotics for acute tonsillitis in pediatric ambulatory care in Taiwan, 2000-2009: A nationwide population-based study.

    Science.gov (United States)

    Chang, Lo-Yi; Lai, Chou-Cheng; Chen, Chun-Jen; Cho, Ching-Yi; Luo, Yu-Cheng; Jeng, Mei-Jy; Wu, Keh-Gong

    2017-08-01

    Acute tonsillitis is the leading diagnosis in pediatric ambulatory care, and group A beta-hemolytic streptococcus is the main reason for antibiotic prescriptions in patients with acute tonsillitis. The aim of this study was to analyze trends in prescribing antibiotics and to investigate the prescription patterns for acute tonsillitis in pediatric ambulatory care in Taiwan from 2000 to 2009. Data on children younger than 18 years with a primary diagnosis of acute tonsillitis were retrieved from the National Health Insurance Research Database of Taiwan from 2000 to 2009. Concomitant bacterial infections were excluded. Sex, age, seasonality, location, level of medical institution, and physician specialty were analyzed. Annual and monthly changes in antibiotic prescriptions and classification were also evaluated. A total of 40,775 cases were enrolled, with an overall antibiotic prescription rate of 16.8%. There was a remarkable decline in the antibiotic prescription rates for tonsillitis from 28.4% in 2000 to 10.9% in 2009. Factors associated with a higher prescription rate included older age, visits from eastern Taiwan, medical centers, and nonpediatrician physicians. Otolaryngologists had higher antibiotic prescription rate, whereas pediatricians had the lowest (21.9% vs. 11.6%). The rates of obtaining throat cultures were low although the culture performing rate in the medical centers was significantly higher (12.3%, p < 0.001). From 2000 to 2009, there was a remarkable decline in the antibiotic prescription rates for tonsillitis. Further studies to evaluate diagnostic tools such as rapid antigen detection tests or throat cultures to decrease antibiotic prescriptions are warranted. Copyright © 2015. Published by Elsevier B.V.

  3. Defining your role in ambulatory care: clinical nurse specialist or nurse practitioner?

    Science.gov (United States)

    Sawyers, J E

    1993-01-01

    A collaborative practice was established at the University of Southern California/Kenneth Norris Jr. Cancer Hospital utilizing combined roles of the CNS and nurse practitioner. The role was created out of a specific need of the physicians of the gastrointestinal malignancy service. Increased administrative and clinical responsibilities necessitated another clinical expert to be readily available for the management of the acute care private practice patients. As a CNS for both the departments of medicine and nursing, my primary responsibilities are focused within the ambulatory care area. This paper presents the concept for this position, the professional and personal benefits, advantages and disadvantages, and recommendations for nursing practice.

  4. Potential collaboration with the private sector for the provision of ambulatory care in the Mekong region, Vietnam

    Science.gov (United States)

    Duc, Ha Anh; Sabin, Lora L.; Cuong, Le Quang; Thien, Duong Duc; Feeley, Rich

    2012-01-01

    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 partnerships, establishing a

  5. Monthly variation of United States pediatric headache emergency department visits.

    Science.gov (United States)

    Kedia, Sita; Ginde, Adit A; Grubenhoff, Joseph A; Kempe, Allison; Hershey, Andrew D; Powers, Scott W

    2014-05-01

    The objective of this article is to determine the monthly variation of emergency department (ED) visits for pediatric headache. We hypothesized youth have increased headache-related ED visits in the months associated with school attendance. Using a United States representative sample of ED visits in the National Hospital Ambulatory Medical Care Survey from 1997 to 2009, we estimated number of visits associated with ICD-9 codes related to headache, migraine, status migrainosus, or tension-type headache in 5- to 18-year-olds. Age-stratified multivariate models are presented for month of visit (July as reference). There was a national estimate of 250,000 ED visits annually related to headache (2.1% of total visits) in 5- to 18-year-olds. In 5- to 11-year-olds, the adjusted rate of headache-related visits was lower in April (OR 0.42, 95% CI 0.20, 0.88). In 12- to 18-year-olds, there were higher rates in January (OR 1.92, 95% CI 1.16, 3.14) and September (OR 1.64, 95% CI 1.06, 2.55). In adolescents we found higher ED utilization in January and September, the same months associated with school return from vacation for a majority of children nationally. No significant reduction in the summer suggests that school itself is not the issue, but rather changes in daily lifestyle and transitions.

  6. Prescribing Safety in Ambulatory Care: Physician Perspectives

    National Research Council Canada - National Science Library

    Rundall, Thomas G; Hsu, John; Lafata, Jennifer E; Fung, Vicki; Paez, Kathryn A; Simpkins, Jan; Simon, Steven R; Robinson, Scott B; Uratsu, Connie; Gunter, Margaret J; Soumerai, Stephen B; Selby, Joseph V

    2005-01-01

    .... We asked about current safety practices, perceptions of ambulatory prescribing safety. Using a content analysis approach, three investigators independently coded responses into thematic categories...

  7. Ambulatory Surgical Measures - Facility

    Data.gov (United States)

    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...

  8. Effect of Pediatric Behavioral Health Screening and Colocated Services on Ambulatory and Inpatient Utilization.

    Science.gov (United States)

    Hacker, Karen A; Penfold, Robert B; Arsenault, Lisa N; Zhang, Fang; Soumerai, Stephen B; Wissow, Lawrence S

    2015-11-01

    The study sought to determine the impact of a pediatric behavioral health screening and colocation model on utilization of behavioral health care. In 2003, Cambridge Health Alliance, a Massachusetts public health system, introduced behavioral health screening and colocation of social workers sequentially within its pediatric practices. An interrupted time-series study was conducted to determine the impact on behavioral health care utilization in the 30 months after model implementation compared with the 18 months prior. Specifically, the change in trends of ambulatory, emergency, and inpatient behavioral health utilization was examined. Utilization data for 11,223 children ages ≥4 years 9 months to <18 years 3 months seen from 2003 to 2008 contributed to the study. In the 30 months after implementation of pediatric behavioral health screening and colocation, there was a 20.4% cumulative increase in specialty behavioral health visit rates (trend of .013% per month, p=.049) and a 67.7% cumulative increase in behavioral health primary care visit rates (trend of .019% per month, p<.001) compared with the expected rates predicted by the 18-month preintervention trend. In addition, behavioral health emergency department visit rates increased 245% compared with the expected rate (trend .01% per month, p=.002). After the implementation of a behavioral health screening and colocation model, more children received behavioral health treatment. Contrary to expectations, behavioral health emergency department visits also increased. Further study is needed to determine whether this is an effect of how care was organized for children newly engaged in behavioral health care or a reflection of secular trends in behavioral health utilization or both.

  9. Ambulatory care sensitive conditions at out-of-hospital emergence services in Croatia: a longitudinal study based on routinely collected data.

    Science.gov (United States)

    Kostanjšek, Diana; Benčić, Miro; Keglević, Mladenka Vrcić

    2014-12-01

    Conditions for which a hospital and emergency utilization can be considered avoidable are often referred as ambulatory care sensitive conditions (ACSCs). Until now, there has been no published research related to ACSCs in Croatia. This study was undertaken with the aim of determining the trends relating to ACSCs in out-of-hospital ES from 1995-2012. The study is based on data from the Croatian Health Service Yearbooks. Five chronic and three acute conditions were chosen: diabetes, hypertension, congestive heart failure, angina pectoris, asthma and COPD, bacterial pneumonia, urinary tract infections and skin infections. The results indicate that the ES in Croatia is overused, and consequently ACSCs are over-represented; 23.3% Croatian citizens visited the ES and around 15% of all diagnoses belonged to the ACSCs, with decreased trend. The leading diagnosis is hypertension, followed by asthma and COPD. For a better understanding of the importance of ACSC within the Croatian context, further research is needed.

  10. Assessing the Burden of Diabetes Mellitus in Emergency Departments in the United States: The National Hospital Ambulatory Medical Care Survey (NHAMCS)

    Science.gov (United States)

    Asao, Keiko; Kaminski, James; McEwen, Laura N.; Wu, Xiejian; Lee, Joyce M.; Herman, William H.

    2014-01-01

    Objective To evaluate the performance of three alternative methods to identify diabetes in patients visiting Emergency Departments (EDs), and to describe the characteristics of patients with diabetes who are not identified when the alternative methods are used. Research Design and Methods We used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2009 and 2010. We assessed the sensitivity and specificity of using providers’ diagnoses and diabetes medications (both excluding and including biguanides) to identify diabetes compared to using the checkbox for diabetes as the gold standard. We examined the characteristics of patients whose diabetes was missed using multivariate Poisson regression models. Results The checkbox identified 5,567 ED visits by adult patients with diabetes. Compared to the checkbox, the sensitivity was 12.5% for providers’ diagnoses alone, 20.5% for providers’ diagnoses and diabetes medications excluding biguanides, and 21.5% for providers’ diagnoses and diabetes medications including biguanides. The specificity of all three of the alternative methods was >99%. Older patients were more likely to have diabetes not identified. Patients with self-payment, those who had glucose measured or received IV fluids in the ED, and those with more diagnosis codes and medications, were more likely to have diabetes identified. Conclusions NHAMCS's providers’ diagnosis codes and medication lists do not identify the majority of patients with diabetes visiting EDs. The newly introduced checkbox is helpful in measuring ED resource utilization by patients with diabetes. PMID:24680472

  11. Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits.

    Science.gov (United States)

    Schoenfeld, Adam J; Davies, Jason M; Marafino, Ben J; Dean, Mitzi; DeJong, Colette; Bardach, Naomi S; Kazi, Dhruv S; Boscardin, W John; Lin, Grace A; Duseja, Reena; Mei, Y John; Mehrotra, Ateev; Dudley, R Adams

    2016-05-01

    Commercial virtual visits are an increasingly popular model of health care for the management of common acute illnesses. In commercial virtual visits, patients access a website to be connected synchronously-via videoconference, telephone, or webchat-to a physician with whom they have no prior relationship. To date, whether the care delivered through those websites is similar or quality varies among the sites has not been assessed. To assess the variation in the quality of urgent health care among virtual visit companies. This audit study used 67 trained standardized patients who presented to commercial virtual visit companies with the following 6 common acute illnesses: ankle pain, streptococcal pharyngitis, viral pharyngitis, acute rhinosinusitis, low back pain, and recurrent female urinary tract infection. The 8 commercial virtual visit websites with the highest web traffic were selected for audit, for a total of 599 visits. Data were collected from May 1, 2013, to July 30, 2014, and analyzed from July 1, 2014, to September 1, 2015. Completeness of histories and physical examinations, the correct diagnosis (vs an incorrect or no diagnosis), and adherence to guidelines of key management decisions. Sixty-seven standardized patients completed 599 commercial virtual visits during the study period. Histories and physical examinations were complete in 417 visits (69.6%; 95% CI, 67.7%-71.6%); diagnoses were correctly named in 458 visits (76.5%; 95% CI, 72.9%-79.9%), and key management decisions were adherent to guidelines in 325 visits (54.3%; 95% CI, 50.2%-58.3%). Rates of guideline-adherent care ranged from 206 visits (34.4%) to 396 visits (66.1%) across the 8 websites. Variation across websites was significantly greater for viral pharyngitis and acute rhinosinusitis (adjusted rates, 12.8% to 82.1%) than for streptococcal pharyngitis and low back pain (adjusted rates, 74.6% to 96.5%) or ankle pain and recurrent urinary tract infection (adjusted rates, 3.4% to 40

  12. Ambulatory phlebectomy at radiologic outpatient clinic

    International Nuclear Information System (INIS)

    Yoon, Chang Jin; Kang, Sung Gwon; Choi, Sang Il; Lee, Whal; Chung, Jin Wook; Park, Jae Hyung

    2007-01-01

    To evaluate safety, efficacy, and patient's satisfaction of an ambulatory phlebectomy, performed at a radiology outpatient clinic. Between 2003 and 2006, an ambulatory phlebectomy was performed in 12 patients. Endovenous radiofrequency ablation was performed through a venotomy. The venotomy was ligated after RF ablation, and the ambulatory phlebectomy was performed. The patients visited the radiology outpatient clinic one day, one week, and 2 months after the procedure. The improvement in the clinical symptoms, cosmetic change in varicosity, and the procedure related complications were evaluated. The patient's satisfaction was evaluated using a 5-grade scale. RF ablation through a venotomy was performed successfully in all 12 patients. On average, 4.5 incisions were made, and 12.5 cm of varicosity had been removed. The mean procedure time was one hour and forty minutes. The complications of the ambulatory phlebectomy were bruising in one patient, and skin pigmentation in another. The complications associated with RF ablation were a hard palpable vein in 7 patients, numbness in 7 patients, and skin pigmentation along the vein in 2 patients. Follow-up duplex sonography was performed at 2 months after the procedure, showed complete occlusion in all 12 patients. The clinical symptoms had improved in 11 patients, and the varicosity disappeared cosmetically in 11 patients. An ambulatory phlebectomy, combined with RF ablation of the greater saphenous vein, can be performed safely and effectively at a radiology outpatient clinic

  13. Ambulatory phlebectomy at radiologic outpatient clinic

    Energy Technology Data Exchange (ETDEWEB)

    Yoon, Chang Jin; Kang, Sung Gwon; Choi, Sang Il [Seoul National University Bundang Hospital, Seongnam (Korea, Republic of); Lee, Whal; Chung, Jin Wook; Park, Jae Hyung [Seoul National University, Medical College, Seoul (Korea, Republic of)

    2007-03-15

    To evaluate safety, efficacy, and patient's satisfaction of an ambulatory phlebectomy, performed at a radiology outpatient clinic. Between 2003 and 2006, an ambulatory phlebectomy was performed in 12 patients. Endovenous radiofrequency ablation was performed through a venotomy. The venotomy was ligated after RF ablation, and the ambulatory phlebectomy was performed. The patients visited the radiology outpatient clinic one day, one week, and 2 months after the procedure. The improvement in the clinical symptoms, cosmetic change in varicosity, and the procedure related complications were evaluated. The patient's satisfaction was evaluated using a 5-grade scale. RF ablation through a venotomy was performed successfully in all 12 patients. On average, 4.5 incisions were made, and 12.5 cm of varicosity had been removed. The mean procedure time was one hour and forty minutes. The complications of the ambulatory phlebectomy were bruising in one patient, and skin pigmentation in another. The complications associated with RF ablation were a hard palpable vein in 7 patients, numbness in 7 patients, and skin pigmentation along the vein in 2 patients. Follow-up duplex sonography was performed at 2 months after the procedure, showed complete occlusion in all 12 patients. The clinical symptoms had improved in 11 patients, and the varicosity disappeared cosmetically in 11 patients. An ambulatory phlebectomy, combined with RF ablation of the greater saphenous vein, can be performed safely and effectively at a radiology outpatient clinic.

  14. [Day hospital in internal medicine: A chance for ambulatory care].

    Science.gov (United States)

    Grasland, A; Mortier, E

    2018-04-16

    Internal medicine is an in-hospital speciality. Along with its expertise in rare diseases, it shares with general medicine the global care of patients but its place in the ambulatory shift has yet to be defined. The objective of our work was to evaluate the benefits of an internal medicine day-hospital devoted to general medicine. Named "Centre Vi'TAL" to underline the link between the city and the hospital, this novel activity was implemented in order to respond quickly to general practitioners having difficulties to synthesize their complex patients or facing diagnostic or therapeutic problems. Using preferentially email for communication, the general practitioners can contact an internist who is committed to respond on the same day and take over the patient within 7 days if day-hospital is appropriate for his condition. The other patients are directed either to the emergency department, consultation or full hospitalization. In 14 months, the center has received 213 (144 women, 69 men) patients, mean age 53.6, addressed by 88 general practitioners for 282 day-hospital sessions. Requests included problem diagnoses (n=105), synthesis reviews for complex patients (n=65), and treatment (n=43). In the ambulatory shift advocated by the authorities, this experience shows that internal medicine should engage in the recognition of day-hospital as a place for diagnosis and synthesis reviews connected with the city while leaving the general practitioners coordinator of their patient care. This activity of synthesis in day-hospital is useful for the patients and efficient for our healthcare system. Copyright © 2018 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier SAS. All rights reserved.

  15. Technical Limitations of Electronic Health Records in Community Health Centers: Implications on Ambulatory Care Quality

    Science.gov (United States)

    West, Christopher E.

    2010-01-01

    Research objectives: This dissertation examines the state of development of each of the eight core electronic health record (EHR) functionalities as described by the IOM and describes how the current state of these functionalities limit quality improvement efforts in ambulatory care settings. There is a great deal of literature describing both the…

  16. Regional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain

    Science.gov (United States)

    Davis, Matthew A.; Yakusheva, Olga; Gottlieb, Daniel J.; Bynum, Julie P.W.

    2015-01-01

    Background Whether availability of chiropractic care affects use of primary care physician (PCP) services is unknown. Methods We performed a cross-sectional study of 17.7 million older adults who were enrolled in Medicare from 2010 to 2011. We examined the relationship between regional supply of chiropractic care and PCP services using Spearman correlation. Generalized linear models were used to examine the association between regional supply of chiropractic care and number of annual visits to PCPs for back and/or neck pain. Results We found a positive association between regional supply of chiropractic care and PCP services (rs = 0.52; P neck pain was apparent. The number of PCP visits for back and/or neck pain was 8% lower (rate ratio, 0.92; 95% confidence interval, 0.91–0.92) in the quintile with the highest supply of chiropractic care compared to the lowest quintile. We estimate chiropractic care is associated with a reduction of 0.37 million visits to PCPs nationally, at a cost of $83.5 million. Conclusions Greater availability of chiropractic care in some areas may be offsetting PCP services for back and/or neck pain among older adults. (J Am Board Fam Med 2015;28:000–000.) PMID:26152439

  17. Impact of Disease Prevalence Adjustment on Hospitalization Rates for Chronic Ambulatory Care-Sensitive Conditions in Germany.

    Science.gov (United States)

    Pollmanns, Johannes; Romano, Patrick S; Weyermann, Maria; Geraedts, Max; Drösler, Saskia E

    2018-04-01

    To explore effects of disease prevalence adjustment on ambulatory care-sensitive hospitalization (ACSH) rates used for quality comparisons. County-level hospital administrative data on adults discharged from German hospitals in 2011 and prevalence estimates based on administrative ambulatory diagnosis data were used. A retrospective cross-sectional study using in- and outpatient secondary data was performed. Hospitalization data for hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, and asthma were obtained from the German Diagnosis Related Groups (DRG) database. Prevalence estimates were obtained from the German Central Research Institute of Ambulatory Health Care. Crude hospitalization rates varied substantially across counties (coefficients of variation [CV] 28-37 percent across conditions); this variation was reduced by prevalence adjustment (CV 21-28 percent). Prevalence explained 40-50 percent of the observed variation (r = 0.65-0.70) in ACSH rates for all conditions except asthma (r = 0.07). Between 30 percent and 38 percent of areas moved into or outside condition-specific control limits with prevalence adjustment. Unadjusted ACSH rates should be used with caution for high-stakes public reporting as differences in prevalence may have a marked impact. Prevalence adjustment should be considered in models analyzing ACSH. © Health Research and Educational Trust.

  18. [The determination of arterial pressure by the physician or the nurse: its relation to ambulatory pressure and left ventricular mass. The MAPA-Madrid Group. Monitorización Ambulatoria de la Presión Arterial (Ambulatory Monitoring of Arterial Pressure)].

    Science.gov (United States)

    Martínez, M A; Aguirre, A; Sánchez, M; Nevado, A; Laguna, I; Torre, A; Manuel, E; Villar, C; García-Puig, J

    1999-12-11

    In the present study we evaluated the influence of the observer's status--physician or nurse--on blood pressure levels and the relationship among clinic blood pressure measurement with ambulatory blood pressure and left ventricle mass. Cross sectional study performed in seven primary care centers. Participating physicians and nurses were trained for blood pressure measurement prior to the study and subsequently retrained at 3 month intervals during the study. Patients included in the study were 122 subjects with mild to moderate hypertension who underwent the following study protocol: a) measurement of clinic blood pressure by physician and nurse, in an independent fashion, on 3 visits; b) clinic-epidemiologic questionnaire; c) conventional hematological and biochemical study; d) electrocardiogram; e) 24-hour ambulatory blood pressure monitoring, f) M-mode and Doppler echocardiography (only in 58 subjects). Nurse-measured blood pressure levels were higher than those determined by physicians (mean differences: 3.9 [6.7] mmHg in systolic blood pressure and 2.6 [5.4] mmHg in diastolic blood pressure). The blood pressure level differences between the two observers were higher in female patients and subjects with low educational level, independently of the observer's gender. Nurse-measured blood pressure was more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure. Nurse-measured blood pressure levels are lower than those determined by physicians and more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure. These data support that nurses, instead of doctors, should routinely measure blood pressure in primary care centers.

  19. Perceptions of Ambulatory Workflow Changes in an Academic Primary Care Setting.

    Science.gov (United States)

    Hanak, Michael A; McDevitt, Colleen; Dunham, Daniel P

    As health care moves to a value-based system, the need for team-based models of care becomes increasingly important to adequately address the growing number of clinical quality metrics required of health care providers. Finding ways to better engage certified medical assistants (CMAs) in the process allows providers to focus on more complex tasks while improving the efficiency of each office visit. Although the roles and responsibilities for CMAs across the specialties can vary widely, standardizing the work can be a helpful step in scaling best practices across an institution. This article presents the results of a survey that evaluated various components of a CMA workflow in adult primary care practices within an academic medical center. Although the survey identified improved engagement and satisfaction with standardized changes overall, it also showed time constraints and provider discretion forcing unplanned modifications. Reviewing and reconciling medications seemed to be the most challenging for CMA staff, leading us to reconsider their involvement in this aspect of each visit. It will be important to continue innovating and testing team-based care models to keep up with the demands of a quality-based health care system.

  20. Innovation in ambulatory care: a collaborative approach to redesigning the health care workplace.

    Science.gov (United States)

    Johnson, Paula A; Bookman, Ann; Bailyn, Lotte; Harrington, Mona; Orton, Piper

    2011-02-01

    To improve the quality of patient care and work satisfaction of the physicians and staff at an ambulatory practice that had recently started an innovative model of clinical care for women. The authors used an inclusive process, collaborative interactive action research, to engage all physicians and staff members in assessing and redesigning their work environment. Based on key barriers to working effectively and integrating work and family identified in that process, a pilot project with new work practices and structures was developed, implemented, and evaluated. The work redesign process established cross-occupational care teams in specific clinical areas. Members of the teams built skills in assessing clinical operations in their practice areas, developed new levels of collaboration, and constructed new models of distributed leadership. The majority of participants reported an improvement in how their area functioned. Integrating work and family/personal life-particularly practices around flexible work arrangements-became an issue for team discussion and solutions, not a matter of individual accommodation by managers. By engaging the workforce, collaborative interactive action research can help achieve lasting change in the health care workplace and increase physicians' and staff members' work satisfaction. This "dual agenda" may be best achieved through a collaborative process where cross-occupational teams are responsible for workflow and outcomes and where the needs of patients and providers are integrated.

  1. Profiling outcomes of ambulatory care: casemix affects perceived performance.

    Science.gov (United States)

    Berlowitz, D R; Ash, A S; Hickey, E C; Kader, B; Friedman, R; Moskowitz, M A

    1998-06-01

    The authors explored the role of casemix adjustment when profiling outcomes of ambulatory care. The authors reviewed the medical records of 656 patients with hypertension, diabetes, or chronic obstructive pulmonary disease (COPD) receiving care at one of three Department of Veterans Affairs medical centers. Outcomes included measures of physiological control for hypertension and diabetes, and of exacerbations for COPD. Predictors of poor outcomes, including physical examination findings, symptoms, and comorbidities, were identified and entered into regression models. Observed minus expected performance was described for each site, both before and after casemix adjustment. Risk-adjustment models were developed that were clinically plausible and had good performance properties. Differences existed among the three sites in the severity of the patients being cared for. For example, the percentage of patients expected to have poor blood pressure control were 35% at site 1, 37% at site 2, and 44% at site 3 (P Casemix-adjusted measures of performance were different from unadjusted measures. Sites that were outliers (P Casemix adjustment models can be developed for outpatient medical conditions. Sites differ in the severity of patients they treat, and adjusting for these differences can alter judgments of site performance. Casemix adjustment is necessary when profiling outpatient medical conditions.

  2. Obstacles and facilitators of open visiting policy in Intensive Care Units:A qualitative study

    Directory of Open Access Journals (Sweden)

    Shiva Khaleghparast

    2016-07-01

    Full Text Available Open visiting policy in intensive care units is proposed as an essential requirement for patients and their families, so this study is aimed to explain open visiting policy obstacles and facilitators from patients, families and health team members’ viewpoint. This qualitative study implemented in intensive care units of a hospital specialized in cardiology in Tehran-Iran. Patients’, families’, nurses’, doctors’ and guards’ viewpoint was determined regarding open visiting policy obstacles and facilitators by semi-structured interviews. Data analysis method was conventional approach of qualitative content analysis with thematic technique. Data analysis was performed using Max QDA10 software. Two main categories of data regarding open visiting obstacles and facilitators were extracted. Factors related to service systems and visitors derived from open visiting obstacles, and factors related to management system and personnel derived from open visiting facilitators. One of the most important obstacles of open visiting policy implementation is shortage of staff and personnel negative attitude. Regarding open visiting policy facilitators, designing visiting cards for close family and observing specific rules, modification of intensive care unit structure and facilities for families are useful. Finally, what is important as an open visiting policy implementation facilitator is presence of nursing profession as a humanitarian and ethical profession.

  3. [Dysphagia rehabilitation in visiting home care].

    Science.gov (United States)

    Tohara, Haruka; Iida, Takatoshi; Inoue, Motoharu; Sato, Mitsuyasu; Wada, Satoko; Sanpei, Ryuichi; Okada, Takeshi; Shimano, Takaya; Ebihara, Katsuko; Ueda, Koichiro

    2010-12-01

    Dysphagia can cause aspiration pneumonia. The condition of dysphagia is difficult to evaluate from outside. Therefore, a careful examination is necessary to grasp the state of swallowing of a patient accurately. However, it has been a difficult situation for a patient who cannot come to hospital for some reason to be examined by video fluoroscopy or video endoscopy. In recent years, a usefulness of video endoscopy in visiting home examination for dysphagia has been reported several times. And this video endoscopy examination is a valuable tool to detect a discrepancy between swallowing function and nutritional intake of the patient. Cooperative rehabilitation with such a careful examination is an important issue to be successful in dysphagia rehabilitation.

  4. Cancer Survivorship Care Plan Utilization and Impact on Clinical Decision-Making at Point-of-Care Visits with Primary Care: Results from an Engineering, Primary Care, and Oncology Collaborative for Survivorship Health.

    Science.gov (United States)

    Donohue, SarahMaria; Haine, James E; Li, Zhanhai; Feldstein, David A; Micek, Mark; Trowbridge, Elizabeth R; Kamnetz, Sandra A; Sosman, James M; Wilke, Lee G; Sesto, Mary E; Tevaarwerk, Amye J

    2017-11-02

    Every cancer survivor and his/her primary care provider should receive an individualized survivorship care plan (SCP) following curative treatment. Little is known regarding point-of-care utilization at primary care visits. We assessed SCP utilization in the clinical context of primary care visits. Primary care physicians and advanced practice providers (APPs) who had seen survivors following provision of an SCP were identified. Eligible primary care physicians and APPs were sent an online survey, evaluating SCP utilization and influence on decision-making at the point-of-care, accompanied by copies of the survivor's SCP and the clinic note. Eighty-eight primary care physicians and APPs were surveyed November 2016, with 40 (45%) responding. Most respondents (60%) reported discussing cancer or related issues during the visit. Information needed included treatment (66%) and follow-up visits, and the cancer team was responsible for (58%) vs primary care (58%). Respondents acquired this information by asking the patient (79%), checking oncology notes (75%), the SCP (17%), or online resources (8%). Barriers to SCP use included being unaware of the SCP (73%), difficulty locating it (30%), and finding needed information faster via another mechanism (15%). Despite largely not using the SCP for the visit (90%), most respondents (61%) believed one would be quite or very helpful for future visits. Most primary care visits included discussion of cancer or cancer-related issues. SCPs may provide the information necessary to deliver optimal survivor care but efforts are needed to reduce barriers and design SCPs for primary care use.

  5. A six-year descriptive analysis of hospitalisations for ambulatory care sensitive conditions among people born in refugee-source countries.

    Science.gov (United States)

    Correa-Velez, Ignacio; Ansari, Zahid; Sundararajan, Vijaya; Brown, Kaye; Gifford, Sandra M

    2007-10-03

    Hospitalisation for ambulatory care sensitive conditions (ACSHs) has become a recognised tool to measure access to primary care. Timely and effective outpatient care is highly relevant to refugee populations given the past exposure to torture and trauma, and poor access to adequate health care in their countries of origin and during flight. Little is known about ACSHs among resettled refugee populations. With the aim of examining the hypothesis that people from refugee backgrounds have higher ACSHs than people born in the country of hospitalisation, this study analysed a six-year state-wide hospital discharge dataset to estimate ACSH rates for residents born in refugee-source countries and compared them with the Australia-born population. Hospital discharge data between 1 July 1998 and 30 June 2004 from the Victorian Admitted Episodes Dataset were used to assess ACSH rates among residents born in eight refugee-source countries, and compare them with the Australia-born average. Rate ratios and 95% confidence levels were used to illustrate these comparisons. Four categories of ambulatory care sensitive conditions were measured: total, acute, chronic and vaccine-preventable. Country of birth was used as a proxy indicator of refugee status. When compared with the Australia-born population, hospitalisations for total and acute ambulatory care sensitive conditions were lower among refugee-born persons over the six-year period. Chronic and vaccine-preventable ACSHs were largely similar between the two population groups. Contrary to our hypothesis, preventable hospitalisation rates among people born in refugee-source countries were no higher than Australia-born population averages. More research is needed to elucidate whether low rates of preventable hospitalisation indicate better health status, appropriate health habits, timely and effective care-seeking behaviour and outpatient care, or overall low levels of health care-seeking due to other more pressing needs during

  6. Comorbidity and health care visit burden in working-age commercially insured patients with diabetic macular edema

    Directory of Open Access Journals (Sweden)

    Kiss S

    2016-12-01

    Full Text Available Szilárd Kiss,1 Hitesh S Chandwani,2 Ashley L Cole,2 Vaishali D Patel,2 Orsolya E Lunacsek,3 Pravin U Dugel4 1Department of Ophthalmology, Weill Cornell Medical College, New York, NY, 2Global Health Economics and Outcomes Research, Allergan, Inc., Irvine, CA, 3Global Health Economics and Outcomes Research, Xcenda, LLC, Palm Harbor, FL, 4Retinal Consultants of Arizona and USC Eye Institute, Phoenix, AZ, USA Purpose: To examine the comorbidity profile and update estimates of health care resource utilization for commercially insured, working-age adults with diabetic macular edema (DME relative to a matched comparison group of diabetic adults without DME. Additional comparisons were made in the subgroup of pseudophakic patients. Patients and methods: A retrospective matched-cohort study of commercially insured diabetic adults aged 18–63 years was conducted using medical and outpatient pharmacy claims (July 1, 2008–June 30, 2013. Outcomes included diabetes-related and ocular comorbidities and health care resource utilization (any health care visit days, outpatient visit days, inpatient visit days, emergency room visits, eye care-related visit days, unique medications in the 12-month post-index period. Results: All diabetes-related and ocular comorbidities were significantly more prevalent in DME cases versus non-DME controls (P<0.05. A significantly greater proportion of DME cases utilized eye care-related visits compared with non-DME controls (P<0.001. DME cases had almost twice the mean number of total health care visit days compared to non-DME controls (28.6 vs 16.9 days, P<0.001, with a minority of visit days being eye care-related (mean 5.1 vs 1.5 days, P<0.001. Similar trends were observed in pseudophakic cohorts. Conclusion: This working-age DME population experienced a mean of 29 health care visit days per year. Eye care-related visit days were a minority of the overall visit burden (mean 5 days emphasizing the trade-offs DME patients

  7. The Elixir of Visiting: A Qualitative Study on the Experiences of Conscious Mechanically Ventilated Patients in Intensive Care Units Regarding Visiting Family Members

    Directory of Open Access Journals (Sweden)

    Fatemeh Hajiabadi

    2017-07-01

    Full Text Available Background: Visiting family members is one of the basic human needs; however, there is contradictory evidence about the advantages and disadvantages of the existing visiting systems.  Therefore, the investigation of patients’ preferences for the visiting strategies, and achievement of their authentic experiences can significantly contribute to decision-making about the type of acceptable and approved policies in this domain. Aim: The aim of this study was to explain the experiences of conscious patients undergoing mechanical ventilation in Intensive Care Units regarding their visits with their family members. Method: This qualitative study was conducted on 15 conscious mechanically ventilated patients admitted to the Intensive Care Unit in Iran in 2017. The data were collected using semi-structured interviews and observations. The sampling was performed through purposive sampling technique, which was continued until data saturation to select the individuals with rich experiences about the subject under investigation. The data were analyzed through the conventional type of qualitative content analysis. Results: Out of the initial 385 codes, 11 subthemes and 5 main themes were extracted during the analysis process, all of which were placed under the general concept of “the elixir of visiting”. The five main themes included visiting as a healing agent, visiting as an agent for the enhancement of perceived support, visiting as an agent for gaining hope, visiting as the patient’s urgent need, and preference for planed visiting. Implications for Practice: The results of the present study showed that visiting was like an elixir for the conscious patients undergoing mechanical ventilation in the Intensive Care Units. This practice could allay lots of their pains and lead to numerous valuable effects, such as elimination of loneliness and sadness, increased hope for survival and recovery, and enhancement of a sense of support. Therefore, nursing

  8. The influence of a mental health home visit service partnership intervention on the caregivers' home visit service satisfaction and care burden.

    Science.gov (United States)

    Cheng, Jui-Fen; Huang, Xuan-Yi; Lin, Mei-Jue; Wang, Ya-Hui; Yeh, Tzu-Pei

    2018-02-01

    To investigate a community-based and hospital-based home visit partnership intervention in improving caregivers' satisfaction with home service and reducing caregiver burden. The community-oriented mental healthcare model prevails internationally. After patients return to the community, family caregivers are the patients' main support system and they also take the most of the burden of caring for patients. It is important to assist these caregivers by building good community healthcare models. A longitudinal quasi-experimental quantitative design. The experimental group (n = 109) involved "partnership" intervention, and the control group (n = 101) maintained routine home visits. The results were measured before the intervention, 6 and 12 months after the partnership intervention. Six months after the partnership intervention, the satisfaction of the experimental group was higher than the control group for several aspects of care. Although the care burden was reduced in the experimental group, there was no significant difference between the two groups. This study confirms that the partnership intervention can significantly improve caregiver satisfaction with home services, without reducing the care burden. The community-based and hospital-based mental health home visit service partnership programme could improve the main caregiver's satisfaction with the mental health home visit services, while the reduction in care burden may need government policies for the provision of more individual and comprehensive assistance. © 2017 John Wiley & Sons Ltd.

  9. Mobile integrated health to reduce post-discharge acute care visits: A pilot study.

    Science.gov (United States)

    Siddle, Jennica; Pang, Peter S; Weaver, Christopher; Weinstein, Elizabeth; O'Donnell, Daniel; Arkins, Thomas P; Miramonti, Charles

    2018-05-01

    Mobile Integrated Health (MIH) leverages specially trained paramedics outside of emergency response to bridge gaps in local health care delivery. To evaluate the efficacy of a MIH led transitional care strategy to reduce acute care utilization. This was a retrospective cohort analysis of a quality improvement pilot of patients from an urban, single county EMS, MIH transitional care initiative. We utilized a paramedic/social worker (or social care coordinator) dyad to provide in home assessments, medication review, care coordination, and improve access to care. The primary outcome compared acute care utilization (ED visits, observation stays, inpatient visits) 90days before MIH intervention to 90days after. Of the 203 patients seen by MIH teams, inpatient utilization decreased significantly from 140 hospitalizations pre-MIH to 26 post-MIH (83% reduction, p=0.00). ED and observation stays, however, increased numerically, but neither was significant. (ED 18 to 19 stays, p=0.98; observation stays 95 to 106, p=0.30) Primary care visits increased 15% (p=0.11). In this pilot before/after study, MIH significantly reduces acute care hospitalizations. Copyright © 2017 Elsevier Inc. All rights reserved.

  10. Developing Staffing Models to Support Population Health Management And Quality Oucomes in Ambulatory Care Settings.

    Science.gov (United States)

    Haas, Sheila A; Vlasses, Frances; Havey, Julia

    2016-01-01

    There are multiple demands and challenges inherent in establishing staffing models in ambulatory heath care settings today. If health care administrators establish a supportive physical and interpersonal health care environment, and develop high-performing interprofessional teams and staffing models and electronic documentation systems that track performance, patients will have more opportunities to receive safe, high-quality evidence-based care that encourages patient participation in decision making, as well as provision of their care. The health care organization must be aligned and responsive to the community within which it resides, fully invested in population health management, and continuously scanning the environment for competitive, regulatory, and external environmental risks. All of these challenges require highly competent providers willing to change attitudes and culture such as movement toward collaborative practice among the interprofessional team including the patient.

  11. [Current Status of Home Visit Programs: Activities and Barriers of Home Care Nursing Services].

    Science.gov (United States)

    Oh, Eui Geum; Lee, Hyun Joo; Kim, Yukyung; Sung, Ji Hyun; Park, Young Su; Yoo, Jae Yong; Woo, Soohee

    2015-10-01

    The purpose of this study was to examine the current status of home care nursing services provided by community health nurses and to identify barriers to the services. A cross-sectional survey was conducted with three types of community health care nurses. Participants were 257 nurses, 46 of whom were hospital based home care nurses, 176 were community based visiting nurses, and 35 were long term care insurance based visiting nurses. A structured questionnaire on 7 domains of home care nursing services with a 4-point Likert scale was used to measure activities and barriers to care. Data were analyzed using SPSS WIN 21.0 program. Hospital based home care nurses showed a high level of service performance activity in the domain of clinical laboratory tests, medications and injections, therapeutic nursing, and education. Community based visiting nurses had a high level of service performance in the reference domain. Long term care insurance based visiting nurses showed a high level of performance in the service domains of fundamental nursing and counseling. The results show that although health care service provided by the three types of community health nurse overlapped, the focus of the service is differentiated. Therefore, these results suggest that existing home care services will need to be utilized efficiently in the development of a new nursing care service for patients living in the community after hospital discharge.

  12. Use of Welcome to Medicare Visits Among Older Adults Following the Affordable Care Act.

    Science.gov (United States)

    Misra, Arpit; Lloyd, Jennifer T; Strawbridge, Larisa M; Wensky, Suzanne G

    2018-01-01

    To encourage greater utilization of preventive services among Medicare beneficiaries, the 2010 Affordable Care Act waived coinsurance for the Welcome to Medicare visit, making this benefit free starting in 2011. The objective of this study was to determine the impact of the Affordable Care Act on Welcome to Medicare visit utilization. A 5% sample of newly enrolled fee-for-service Medicare beneficiaries for 2005-2016 was used to estimate changes in Welcome to Medicare visit use over time. An interrupted time series model examined whether Welcome to Medicare visits increased significantly after 2011, controlling for pre-intervention trends and other autocorrelation. Annual Welcome to Medicare visit rates began at 1.4% in 2005 and increased to 12.3% by 2016. The quarterly Welcome to Medicare visit rate, which was almost 1% at baseline, was increasing by 0.06% before the 2011 Affordable Care Act provision (pAct provision, the rate increased by about 1% in the first quarter of 2011 (intercept, pAct trends of lower utilization persisted over time for non-whites and improved less quickly for men, regions other than Northeast, and beneficiaries without any supplemental insurance. The Affordable Care Act, and perhaps the removal of cost sharing, was associated with increased use of the Welcome to Medicare visit; however, even with the increased use, there is room for improvement. Published by Elsevier Inc.

  13. Ambulatory cleft lip surgery: A value analysis.

    Science.gov (United States)

    Arneja, Jugpal S; Mitton, Craig

    2013-01-01

    Socialized health systems face fiscal constraints due to a limited supply of resources and few reliable ways to control patient demand. Some form of prioritization must occur as to what services to offer and which programs to fund. A data-driven approach to decision making that incorporates outcomes, including safety and quality, in the setting of fiscal prudence is required. A value model championed by Michael Porter encompasses these parameters, in which value is defined as outcomes divided by cost. To assess ambulatory cleft lip surgery from a quality and safety perspective, and to assess the costs associated with ambulatory cleft lip surgery in North America. Conclusions will be drawn as to how the overall value of cleft lip surgery may be enhanced. A value analysis of published articles related to ambulatory cleft lip repair over the past 30 years was performed to determine what percentage of patients would be candidates for ambulatory cleft lip repair from a quality and safety perspective. An economic model was constructed based on costs associated with the inpatient stay related to cleft lip repair. On analysis of the published reports in the literature, a minority (28%) of patients are currently discharged in an ambulatory fashion following cleft lip repair. Further analysis suggests that 88.9% of patients would be safe candidates for same-day discharge. From an economic perspective, the mean cost per patient for the overnight admission component of ambulatory cleft surgery to the health care system in the United States was USD$2,390 and $1,800 in Canada. The present analysis reviewed germane publications over a 30-year period, ultimately suggesting that ambulatory cleft lip surgery results in preservation of quality and safety metrics for most patients. The financial model illustrates a potential cost saving through the adoption of such a practice change. For appropriately selected patients, ambulatory cleft surgery enhances overall health care value.

  14. Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates.

    Science.gov (United States)

    Szilagyi, Peter G; Humiston, Sharon G; Gallivan, Sarah; Albertin, Christina; Sandler, Martha; Blumkin, Aaron

    2011-06-01

    To assess the impact of a tiered patient immunization navigator intervention (immunization tracking, reminder/recall, and outreach) on improving immunization and preventive care visit rates in urban adolescents. Randomized clinical trial allocating adolescents (aged 11-15 years) to intervention vs standard of care control. Eight primary care practices. Population-based sample of adolescents (N = 7546). Immunization navigators at each practice implemented a tiered protocol: immunization tracking, telephone or mail reminder/recall, and home visits if participants remained unimmunized or behind on preventive care visits. Immunization rates at study end. Secondary outcomes were preventive care visit rates during the previous 12 months and costs. The intervention and control groups were similar at baseline for demographics (mean age, 13.5 years; 63% black, 14% white, and 23% Hispanic adolescents; and 74% receiving Medicaid), immunization rates, and preventive care visit rates. Immunization rates at the end of the study were 44.7% for the intervention group and 32.4% for the control group (adjusted risk ratio, 1.4; 95% confidence interval, 1.3-1.5); preventive care visit rates were 68.0% for the intervention group and 55.2% for the control group (1.2; 1.2-1.3). Findings were similar across practices, sexes, ages, and insurance providers. The number needed to treat for immunizations and preventive care visits was 9. The intervention cost was $3.81 per adolescent per month; the cost per additional adolescent fully vaccinated was $465, and the cost per additional adolescent receiving a preventive care visit was $417. A tiered tracking, reminder/recall, and outreach intervention improved immunization and preventive care visit rates in urban adolescents. clinicaltrials.gov Identifier: NCT00581347.

  15. Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room

    OpenAIRE

    Gottschalk, Andrew; Flocke, Susan A.

    2005-01-01

    PURPOSE Contrary to physicians’ concerns that face-to-face patient time is decreasing, data from the National Ambulatory Medical Care Survey (NAMCS) indicate that between 1988 and 1998, durations of primary care outpatient visits have increased. This study documented how physicians spend time during the workday, including time outside the examination room, and compared observed face-to-face patient care time with that reported in NAMCS.

  16. [Comparative analysis of efficiency indicators in ambulatory surgery].

    Science.gov (United States)

    Rodríguez Ortega, María; Porrero Carro, José Luis; Aranaz Andrés, Jesús María; Castillo Fe, María José; Alonso García, María Teresa; Sánchez-Cabezudo Díaz-Guerra, Carlos

    2017-05-25

    To find comparative elements for quality control in major ambulatory surgery (MAS) units. Descriptive and comparative study of the Ambulatory Care Index (AI) and Substitution Index (SI) in the Santa Cristina Hospital Surgery Service (Madrid, Spain) compared to Key Indicators (KI) of the National Health Service (NHS). 7,817 MAS procedures (between 2006 and 2014) were analysed. The average annual AI was 54%, higher (p <0.0001) than «ambulatory surgery» KI. The hernia outpatient procedures (average 72%) were also superior to the national KI (p <0.0001), but ambulatory haemorrhoidectomy (average 33.6%) was clearly lower (p <0.0001). KI of the NHS are useful and allow to establish a proper development in the global AI and hernia outpatient surgery with opportunities for improvement in haemorrhoidectomy. Their collection should be careful, not including minor surgeries. Also, their usefulness could be increased if data was broken down by speciality and by complexity. Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

  17. Patient-as-observer approach: an alternative method for hand hygiene auditing in an ambulatory care setting.

    Science.gov (United States)

    Le-Abuyen, Sheila; Ng, Jessica; Kim, Susie; De La Franier, Anne; Khan, Bibi; Mosley, Jane; Gardam, Michael

    2014-04-01

    A survey pilot asked patients to observe the hand hygiene compliance of their health care providers. Patients returned 75.1% of the survey cards distributed, and the overall hand hygiene compliance was 96.8%. Survey results and patient commentary were used to motivate hand hygiene compliance. The patient-as-observer approach appeared to be a viable alternative for hand hygiene auditing in an ambulatory care setting because it educated, engaged, and empowered patients to play a more active role in their own health care. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

  18. Ambulatory anesthetic care in pediatric tonsillectomy: challenges and risks

    Directory of Open Access Journals (Sweden)

    Collins C

    2015-11-01

    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

  19. Impact of Marijuana Legalization in Colorado on Adolescent Emergency and Urgent Care Visits.

    Science.gov (United States)

    Wang, George Sam; Davies, Sara Deakyne; Halmo, Laurie Seidel; Sass, Amy; Mistry, Rakesh D

    2018-03-30

    Approximately 6%-8% of U.S. adolescents are daily/past-month users of marijuana. However, survey data may not reliably reflect the impact of legalization on adolescents. The objective was to evaluate the impact of marijuana legalization on adolescent emergency department and urgent cares visits to a children's hospital in Colorado, a state that has allowed both medical and recreational marijuana. Retrospective review of marijuana-related visits by International Classification of Diseases codes and urine drug screens, from 2005 through 2015, for patients ≥ 13 and marijuana-related visits were identified. Behavioral health evaluation was obtained for 2,813 (67%); a psychiatric diagnosis was made for the majority (71%) of these visits. Coingestants were common; the most common was ethanol (12%). Marijuana-related visits increased from 1.8 per 1,000 visits in 2009 to 4.9 in 2015. (p = marijuana use, our data demonstrate a significant increase in adolescent marijuana-associated emergency department and urgent cares visits in Colorado. Copyright © 2018 The Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

  20. The financial and health burden of diabetic ambulatory care sensitive hospitalisations in Mexico.

    Science.gov (United States)

    Lugo-Palacios, David G; Cairns, John

    2016-01-01

    To estimate the financial and health burden of diabetic ambulatory care sensitive hospitalisations (ACSH) in Mexico during 2001-2011. We identified ACSH due to diabetic complications in general hospitals run by local health ministries and estimated their financial cost using diagnostic related groups. The health burden estimation assumes that patients would not have experienced complications if they had received appropriate primary care and computes the associated Disability-Adjusted Life Years (DALYs). The financial cost of diabetic ACSH increased by 125% in real terms and their health burden in 2010 accounted for 4.2% of total DALYs associated with diabetes in Mexico. Avoiding preventable hospitalisations could free resources within the health system for other health purposes. In addition, patients with ACSH suffer preventable losses of health that should be considered when assessing the performance of any primary care intervention.

  1. Mental Health Service Use for Patients with Co-occurring Mental and Physical Chronic Health Care Needs in Primary Care Settings

    Science.gov (United States)

    Haynes-Maslow, Lindsey; Roberts, Megan C.; Dusetzina, Stacie B.

    2016-01-01

    Background Individuals with mental illness experience poor health and may die prematurely from chronic illness. Understanding whether the presence of co-occurring chronic physical health conditions complicates mental health treatment is important, particularly among patients seeking treatment in primary care settings. Objectives Examine (1) whether the presence of chronic physical conditions is associated with mental health service use for individuals with depression who visit a primary care physician, and (2) whether race modifies this relationship. Research Design Secondary analysis of the National Ambulatory Medical Care Survey, a survey of patient-visits collected annually from a random sample of 3,000 physicians in office-based settings. Subjects Office visits from 2007–2010 were pooled for adults ages 35–85 with a depression diagnosis at the time of visit (N=3,659 visits). Measures Mental health services were measured using a dichotomous variable indicating whether mental health services were provided during the office visit or a referral made for: (1) counseling, including psychotherapy and other mental health counseling and/or (2) prescribing of psychotropic medications. Results Most patient office visits (70%) where a depression diagnosis was recorded also had co-occurring chronic physical conditions recorded. The presence of at least one physical chronic condition was associated with a 6% decrease in the probability of receiving any mental health services (pneeded on medical care delivery among patients with co-occurring health conditions, particularly as the health care system moves towards an integrated care model. PMID:26147863

  2. Addressing Pediatric Obesity in Ambulatory Care: Where Are We and Where Are We Going?

    Science.gov (United States)

    Lenders, Carine M; Manders, Aaron J; Perdomo, Joanna E; Ireland, Kathy A; Barlow, Sarah E

    2016-06-01

    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.

  3. Evaluation of the Medical Care of Patients with Hypertension in an Emergency Department and in Ambulatory Hypertension Unit

    Directory of Open Access Journals (Sweden)

    Fernando Nobre

    2002-02-01

    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.

  4. Prevalence of Depressive Disorder of Outpatients Visiting Two Primary Care Settings.

    Science.gov (United States)

    Jo, Sun-Jin; Yim, Hyeon Woo; Jeong, Hyunsuk; Song, Hoo Rim; Ju, Sang Yhun; Kim, Jong Lyul; Jun, Tae-Youn

    2015-09-01

    Although the prevalence of depressive disorders in South Korea's general population is known, no reports on the prevalence of depression among patients who visit primary care facilities have been published. This preliminary study was conducted to identify the prevalence of depressive disorder in patients that visit two primary care facilities. Among 231 consecutive eligible patients who visited two primary care settings, 184 patients consented to a diagnostic interview for depression by psychiatrists following the Diagnostic and Statistical Manual of Mental Disorders-IV criteria. There were no significant differences in sociodemographic characteristics such as gender, age, or level of education between the groups that consented and declined the diagnostic examination. The prevalence of depressive disorder and the proportion of newly diagnosed patients among depressive disorder patients were calculated. The prevalence of depressive disorder of patients in the two primary care facilities was 14.1% (95% confidence interval [CI], 9.1 to 19.2), with major depressive disorder 5.4% (95% CI, 2.1 to 8.7), dysthymia 1.1% (95% CI, 0.0 to 2.6), and depressive disorder, not otherwise specified 7.6% (95% CI, 3.7 to 11.5). Among the 26 patients with depressive disorder, 19 patients were newly diagnosed. As compared to the general population, a higher prevalence of depressive disorders was observed among patients at two primary care facilities. Further study is needed with larger samples to inform the development of a primary care setting-based depression screening, management, and referral system to increase the efficiency of limited health care resources.

  5. Prevalence of Depressive Disorder of Outpatients Visiting Two Primary Care Settings

    Directory of Open Access Journals (Sweden)

    Sun-Jin Jo

    2015-09-01

    Full Text Available Objectives: Although the prevalence of depressive disorders in South Korea’s general population is known, no reports on the prevalence of depression among patients who visit primary care facilities have been published. This preliminary study was conducted to identify the prevalence of depressive disorder in patients that visit two primary care facilities. Methods: Among 231 consecutive eligible patients who visited two primary care settings, 184 patients consented to a diagnostic interview for depression by psychiatrists following the Diagnostic and Statistical Manual of Mental Disorders-IV criteria. There were no significant differences in sociodemographic characteristics such as gender, age, or level of education between the groups that consented and declined the diagnostic examination. The prevalence of depressive disorder and the proportion of newly diagnosed patients among depressive disorder patients were calculated. Results: The prevalence of depressive disorder of patients in the two primary care facilities was 14.1% (95% confidence interval [CI], 9.1 to 19.2, with major depressive disorder 5.4% (95% CI, 2.1 to 8.7, dysthymia 1.1% (95% CI, 0.0 to 2.6, and depressive disorder, not otherwise specified 7.6% (95% CI, 3.7 to 11.5. Among the 26 patients with depressive disorder, 19 patients were newly diagnosed. Conclusions: As compared to the general population, a higher prevalence of depressive disorders was observed among patients at two primary care facilities. Further study is needed with larger samples to inform the development of a primary care setting-based depression screening, management, and referral system to increase the efficiency of limited health care resources.

  6. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status.

    Science.gov (United States)

    Ferrer, Robert L

    2007-01-01

    Long-term shifts in specialty choice and health workforce policy have raised concern about the future of primary care in the United States. The objective of this study was to examine current use of primary and specialty care across the US population for policy-relevant subgroups, such as disadvantaged populations and persons with chronic illness. Data from the Medical Expenditure Panel Survey from 2004 were analyzed using a probability sample patients or other participants from the noninstitutionalized US population in 2004 (N = 34,403). The main and secondary outcome measures were the estimates of the proportion of Americans who accessed different types of primary care and specialty physicians and midlevel practitioners, as well as the fraction of ambulatory visits accounted for by the different clinician types. Data were disaggregated by income, health insurance status, race/ethnicity, rural or urban residence, and presence of 5 common chronic diseases. Family physicians were the most common clinician type accessed by adults, seniors, and reproductive-age women, and they were second to pediatricians for children. Disadvantaged adults with 3 markers of disadvantage (poverty, disadvantaged minority, uninsured) received 45.6% (95% CI, 40.4%-50.7%) of their ambulatory visits from family physicians vs 30.5% (95% CI, 30.0%-32.1%) for adults with no markers. For children with 3 vs 0 markers of disadvantage, the proportion of visits from family physicians roughly doubled from 16.5% (95% CI, 14.4%-18.6%) to 30.1% (95% CI, 18.8%-41.2%). Family physicians constitute the only clinician group that does not show income disparities in access. Multivariate analyses show that patterns of access to family physicians and nurse-practitioners are more equitable than for other clinician types. Primary care clinicians, especially family physicians, deliver a disproportionate share of ambulatory care to disadvantaged populations. A diminished primary care workforce will leave

  7. A six-year descriptive analysis of hospitalisations for ambulatory care sensitive conditions among people born in refugee-source countries

    Directory of Open Access Journals (Sweden)

    Brown Kaye

    2007-10-01

    Full Text Available Abstract Background Hospitalisation for ambulatory care sensitive conditions (ACSHs has become a recognised tool to measure access to primary care. Timely and effective outpatient care is highly relevant to refugee populations given the past exposure to torture and trauma, and poor access to adequate health care in their countries of origin and during flight. Little is known about ACSHs among resettled refugee populations. With the aim of examining the hypothesis that people from refugee backgrounds have higher ACSHs than people born in the country of hospitalisation, this study analysed a six-year state-wide hospital discharge dataset to estimate ACSH rates for residents born in refugee-source countries and compared them with the Australia-born population. Methods Hospital discharge data between 1 July 1998 and 30 June 2004 from the Victorian Admitted Episodes Dataset were used to assess ACSH rates among residents born in eight refugee-source countries, and compare them with the Australia-born average. Rate ratios and 95% confidence levels were used to illustrate these comparisons. Four categories of ambulatory care sensitive conditions were measured: total, acute, chronic and vaccine-preventable. Country of birth was used as a proxy indicator of refugee status. Results When compared with the Australia-born population, hospitalisations for total and acute ambulatory care sensitive conditions were lower among refugee-born persons over the six-year period. Chronic and vaccine-preventable ACSHs were largely similar between the two population groups. Conclusion Contrary to our hypothesis, preventable hospitalisation rates among people born in refugee-source countries were no higher than Australia-born population averages. More research is needed to elucidate whether low rates of preventable hospitalisation indicate better health status, appropriate health habits, timely and effective care-seeking behaviour and outpatient care, or overall low levels

  8. Patient satisfaction and positive patient outcomes in ambulatory anesthesia

    Directory of Open Access Journals (Sweden)

    Shah U

    2015-04-01

    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

  9. A real life clinical practice of neurologists in the ambulatory setting in Thailand: a pragmatic study

    Directory of Open Access Journals (Sweden)

    Kannikar Kongbunkiat

    2015-06-01

    Full Text Available The burden of neurological disorders is high in developing countries. Real life data from neurologists as to how they practice in Thailand are limited in literature. Practices of neurologists in a university hospital clinical setting in Thailand were studied. A prospective study was performed at the ambulatory neurology clinic, Khon Kaen University Hospital, between 1 February and 31 October 2009. The following data were recorded: numbers of patients, characteristics of patients, consultation notes, and time spent for each patient. There were three neurologists, each of whom ran one afternoon clinic, once a week. There were 6137 visits during the 9 months, with an average of 681 visits per month. The total number of patients was 2834. The three most common diseases were cerebrovascular diseases (33%, epilepsy (16%, and movement disorders (non-Parkinson’s disease, 12%. Neurologists spent an average of 6.34 minutes per patient. In conclusion, neurologists in medical schools have limited time to take care of each patient. Several strategies are needed in medical education and neurology training to improve the quality of care.

  10. Utilisation of information technologies in ambulatory care in Switzerland.

    Science.gov (United States)

    Rosemann, Thomas; Marty, Franz; Bhend, Heinz; Wagner, Judith; Brunner, Lorenzo; Zoller, Marco

    2010-09-13

    The importance of electronic medical records for the healthcare system is well documented. IT enables easy storage, communication and decision support and can provide important tools in the care of chronically ill patients in the form of a reminder system. A questionnaire was developed and send out to 1200 physicians extracted from the official data base. After four weeks the non-responders received a written reminder. Data collection started in December 2007 and was completed in February 2008. 719 questionnaires were received back, representing a response rate of 59.9%. The data revealed a significant underuse of electronic medical records (EMRs) and IT compared to other European countries. Smaller practices, older physicians and especially primary care physicians tended to use less EMR. Only 10.2% of all physicians declared an interest in considering investment in IT in the next three years, 66.9% expressly denied wishing to do so. The most important barriers were the costs, the unclear benefit and a feared worsening of the doctor-patient-communication during consultation. IT and especially EMRs are underused in daily ambulatory care in Switzerland. To increase the use of EMRs, several approaches could be helpful. First of all, the benefit of EMRs in daily routine care have to be increased as, for example, by decision support systems, tools to avoid pharmaceutical interactions and reminder systems to enable a proactive treatment of chronically ill patients. Furthermore, adequate approaches to offer appropriate reimbursement for the financial investments have to considered such as an additional payment for electronically generated, evidence based quality indicators.

  11. Identifying consumer segments in health services markets: an application of conjoint and cluster analyses to the ambulatory care pharmacy market.

    Science.gov (United States)

    Carrol, N V; Gagon, J P

    1983-01-01

    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.

  12. Marketing strategy adjustments in the ambulatory care center industry: implications for community pharmacy.

    Science.gov (United States)

    Phillips, J H

    1989-01-01

    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.

  13. Patients' quality of life and role of the ambulatory in after-surgery stoma care. A single center experience.

    Science.gov (United States)

    Magistri, Paolo; Scordamaglia, Maria Rosa; Giulitti, Diego; Papaspyropoulos, Vassilios; Eleuteri, Edoardo; Coppola, Marcello

    2014-01-01

    The aim is to assess on which aspects of everyday-life the post surgery stoma-care ambulatory should physically and psychologically assist the patients. Seventy patients (33 male, 37 female, mean age 68 years) accepted to fill-in the Stoma-QoL questionnaire from January to December 2011. The questionnaire consists of 20 questions addressing different possible discomforts of everyday life. Our results demonstrate that patients with temporary ileostomy have a mean score of quality of life index of 63. Patients with ileostomy demonstrated a higher quality of life score compared to patients with colostomy. Our results confirmed that patients with ileostomy have a better perception of quality of life compared to patients with colostomy. Moreover, our data clearly show that patients are more concerned on stoma management compared to the hypothetical prejudice of society. The stoma care ambulatory have a crucial role, offering to the patient and his/her family an adequate psychological support, and teaching the management of the stoma and the pouch.

  14. The financial and health burden of diabetic ambulatory care sensitive hospitalisations in Mexico

    Directory of Open Access Journals (Sweden)

    David G Lugo-Palacios

    2016-01-01

    Full Text Available Objective.To estimate the financial and health burden of diabetic ambulatory care sensitive hospitalisations (ACSH in Mexico during 2001-2011. Materials and methods. We identified ACSH due to diabetic complications in general hospitals run by local health ministries and estimated their financial cost using diagnostic related groups. The health burden estimation assumes that patients would not have experienced complications if they had received appropriate primary care and computes the associated DisabilityAdjusted Life Years (DALYs. Results. The financial cost of diabetic ACSH increased by 125% in real terms and their health burden in 2010 accounted for 4.2% of total DALYs associated with diabetes in Mexico. Conclusion. Avoiding preventable hospitalisations could free resources within the health system for other health purposes. In addition, patients with ACSH suffer preventable losses of health that should be considered when assessing the performance of any primary care intervention.

  15. Ambulatory anesthesia: optimal perioperative management of the diabetic patient

    Directory of Open Access Journals (Sweden)

    Polderman JAW

    2016-05-01

    Full Text Available Jorinde AW Polderman, Robert van Wilpe, Jan H Eshuis, Benedikt Preckel, Jeroen Hermanides Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands Abstract: Given the growing number of patients with diabetes mellitus (DM and the growing number of surgical procedures performed in an ambulatory setting, DM is one of the most encountered comorbidities in patients undergoing ambulatory surgery. Perioperative management of ambulatory patients with DM requires a different approach than patients undergoing major surgery, as procedures are shorter and the stress response caused by surgery is minimal. However, DM is a risk factor for postoperative complications in ambulatory surgery, so should be managed carefully. Given the limited time ambulatory patients spend in the hospital, improvement in management has to be gained from the preanesthetic assessment. The purpose of this review is to summarize current literature regarding the anesthesiologic management of patients with DM in the ambulatory setting. We will discuss the risks of perioperative hyperglycemia together with the pre-, intra-, and postoperative considerations for these patients when encountered in an ambulatory setting. Furthermore, we provide recommendations for the optimal perioperative management of the diabetic patient undergoing ambulatory surgery. Keywords: diabetes mellitus, perioperative period, ambulatory surgery, insulin, complications, GLP-1 agonist, DPP-4 inhibitor

  16. Anesthesia for ambulatory anorectal surgery.

    Science.gov (United States)

    Gudaityte, Jūrate; Marchertiene, Irena; Pavalkis, Dainius

    2004-01-01

    The prevalence of minor anorectal diseases is 4-5% of adult Western population. Operations are performed on ambulatory or 24-hour stay basis. Requirements for ambulatory anesthesia are: rapid onset and recovery, ability to provide quick adjustments during maintenance, lack of intraoperative and postoperative side effects, and cost-effectiveness. Anorectal surgery requires deep levels of anesthesia. The aim is achieved with 1) regional blocks alone or in combination with monitored anesthesia care or 2) deep general anesthesia, usually with muscle relaxants and tracheal intubation. Modern general anesthetics provide smooth, quickly adjustable anesthesia and are a good choice for ambulatory surgery. Popular regional methods are: spinal anesthesia, caudal blockade, posterior perineal blockade and local anesthesia. The trend in regional anesthesia is lowering the dose of local anesthetic, providing selective segmental block. Adjuvants potentiating analgesia are recommended. Postoperative period may be complicated by: 1) severe pain, 2) urinary retention due to common nerve supply, and 3) surgical bleeding. Complications may lead to hospital admission. In conclusion, novel general anesthetics are recommended for ambulatory anorectal surgery. Further studies to determine an optimal dose and method are needed in the group of regional anesthesia.

  17. Optimizing the Office Visit for Adolescents with Special Health Care Needs.

    Science.gov (United States)

    Nathawad, Rita; Hanks, Christopher

    2017-08-01

    Youth with special health care needs (YSHCN) experience health care disparities and often need additional support to receive optimal medical care, particularly in adolescence as they prepare to transition to adult care. Many medical practices struggle to address their needs. Here, we discuss approaches to improve medical care in office-based settings for YSHCN. Office visits can be optimized by training staff in developmentally appropriate care and ensuring that the physical office space facilitates care. Participating in previsit preparation, including managing patient registries of YSHCN, engaging in regular team huddles, and incorporating previsit planning, can improve preparation and ensure that important needs are not overlooked. Additionally, approaches to improve patient and medical provider comfort with office visits with YSHCN, including approaches to measuring vital signs, examining patients, and communicating with patients with various disabilities, are reviewed. Finally, we discuss methods of supporting adolescents with special health care needs in developing self-management skills that will allow them to be better prepared to enter adult health care settings when appropriate. Although YSHCN can present challenges to medical teams, their care can be improved by developing office-based changes and processes to support improved care for these patients. This may help overcome the health care disparities they experience and increase comfort for all members of the medical team. Copyright © 2017. Published by Elsevier Inc.

  18. Small Cash Incentives Can Encourage Primary Care Visits By Low-Income People With New Health Care Coverage.

    Science.gov (United States)

    Bradley, Cathy J; Neumark, David

    2017-08-01

    In a randomized controlled trial, we studied low-income adults newly covered by a primary care program to determine whether a cash incentive could encourage them to make an initial visit to a primary care provider. Subjects were randomly assigned to one of four groups: three groups whose members received $10 to complete a baseline survey during an interview and who were randomized to incentives of $50, $25, or $0 to visit their assigned primary care provider within six months after enrolling in the study; and a nonincentivized control group not contacted by the research team. Subjects in the $50 and $25 incentive groups were more likely to see a primary care provider (77 percent and 74 percent, respectively), compared to subjects in the $0 incentive group (68 percent). The effects of the intervention were about twice as large when we compared the proportions of subjects in the $50 and $25 incentive groups who visited their providers and the proportion in the nonincentivized group (61 percent). Cash incentive programs may steer newly covered low-income patients toward primary care, which could result in improved health outcomes and lower costs. Project HOPE—The People-to-People Health Foundation, Inc.

  19. Comparative effectiveness research in DARTNet primary care practices: point of care data collection on hypoglycemia and over-the-counter and herbal use among patients diagnosed with diabetes.

    Science.gov (United States)

    Libby, Anne M; Pace, Wilson; Bryan, Cathy; Anderson, Heather Orton; Ellis, Samuel L; Allen, Richard Read; Brandt, Elias; Huebschmann, Amy G; West, David; Valuck, Robert J

    2010-06-01

    The Distributed Ambulatory Research in Therapeutics Network (DARTNet) is a federated network of electronic health record (EHR) data, designed as a platform for next-generation comparative effectiveness research in real-world settings. DARTNet links information from nonintegrated primary care clinics that use EHRs to deliver ambulatory care to overcome limitations with traditional observational research. Test the ability to conduct a remote, electronic point of care study in DARTNet practices by prompting clinic staff to obtain specific information during a patient encounter. Prospective survey of patients identified through queries of clinical data repositories in federated network organizations. On patient visit, survey is triggered and data are relinked to the EHR, de-identified, and copied for evaluation. Adult patients diagnosed with diabetes mellitus that scheduled a clinic visit for any reason in a 2-week period in DARTNet primary care practices. Survey on hypoglycemic events (past month) and over-the-counter and herbal supplement use. DARTNet facilitated point of care data collection triggered by an electronic prompt for additional information at a patient visit. More than one-third of respondents (33% response rate) reported either mild (45%) or severe hypoglycemic events (5%) in the month before the survey; only 3 of those were also coded using the ICD-9 (a significant difference in detection rates 37% vs. 1%). Nearly one-quarter of patients reported taking an OTC/herbal, 4% specifically for the treatment of symptoms of diabetes. Prospective data collection is feasible in DARTNet and can enable comparative effectiveness and safety research.

  20. Influenza-like-illness and clinically diagnosed flu: disease burden, costs and quality of life for patients seeking ambulatory care or no professional care at all.

    Science.gov (United States)

    Bilcke, Joke; Coenen, Samuel; Beutels, Philippe

    2014-01-01

    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.

  1. Influenza-like-illness and clinically diagnosed flu: disease burden, costs and quality of life for patients seeking ambulatory care or no professional care at all.

    Directory of Open Access Journals (Sweden)

    Joke Bilcke

    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.

  2. Advances in the use of intravenous techniques in ambulatory anesthesia

    Directory of Open Access Journals (Sweden)

    Eng MR

    2015-07-01

    Full Text Available Matthew R Eng,1 Paul F White1,2 1Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; 2White Mountain Institute, The Sea Ranch, CA, USA Summary statement: Advances in the use of intravenous techniques in ambulatory anesthesia has become important for the anesthesiologist as the key perioperative physician in outpatient surgery. Key techniques and choices of anesthetics are important in accomplishing fast track goals of ambulatory surgery. Purpose of review: The anesthesiologist in the outpatient environment must focus on improving perioperative efficiency and reducing recovery times while accounting for patients' well-being and safety. This review article focuses on recent intravenous anesthetic techniques to accomplish these goals. Recent findings: This review is an overview of techniques in intravenous anesthesia for ambulatory anesthesia. Intravenous techniques may be tailored to accomplish outpatient surgery goals for the type of surgical procedure and individual patient needs. Careful anesthetic planning and the application of the plans are critical to an anesthesiologist's success with fast-track ambulatory surgery. Conclusion: Careful planning and application of intravenous techniques are critical to an anesthesiologist's success with fast-track ambulatory surgery. Keywords: intravenous anesthesia, outpatient anesthesia, fast-track surgery

  3. Baseline Knowledge and Education on Patient Safety in the Ambulatory Care Setting for 4th Year Pharmacy Students

    Directory of Open Access Journals (Sweden)

    Jessica W. Skelley

    2015-01-01

    Full Text Available Objectives: To assess the baseline knowledge of fourth year student pharmacists on their ability to properly identify and categorize medication related problems (MRP during their Advanced Pharmacy Practice Experience (APPE in the ambulatory care setting, and to assess the efficacy of a written resource designed to educate and train users on identification and documentation of MRP's and used for this purpose with participating students on their ambulatory care APPE. Methods: A pretest consisting of ten multiple-choice questions was administered electronically to fourth year student pharmacists (N=18 at the start of their ambulatory care APPE. The test was designed to assess both the students' baseline knowledge regarding MRP's, and their ability to identify a wide variety of medication-related problems. Students then received a written copy of The Medication Therapy Intervention & Safety Documentation Program training manual and were asked to read it in its entirety in the first week of their APPE. Finally, students were given a posttest survey (identical to the pretest to complete to assess if their knowledge had increased from baseline. Results: The average score for the 18 students taking the baseline knowledge pre-test was 63.33%, indicating limited baseline knowledge regarding the identification and classification of MRP's. In assessing the effectiveness of the written training document, the overall posttest results compared to pretest results did not indicate improvement in students' knowledge or ability to properly identify and classify medication related problems (MRP after reviewing the training manual. The average scores declined from 63.33% on the pretest to 62.78% on the posttest, although this was not found to be statistically significant (p = 0.884. However, a statistically significant decline in students' knowledge occurred on one specific question, which tested their ability to classify MRP's (p = 0.029. Conclusions: Based on the

  4. Clinical, social and relational determinants of paediatric ambulatory drug prescriptions due to respiratory tract infections in Italy.

    Science.gov (United States)

    Ciofi degli Atti, Marta Luisa; Massari, Marco; Bella, Antonino; Boccia, Delia; Filia, Antonietta; Salmaso, Stefania

    2006-12-01

    Collecting information on patterns of drug prescriptions and on factors influencing prescribing decisions is fundamental for supporting the rational use of drugs. This study was aimed at investigating patterns of drug prescription in paediatric outpatients and at evaluating determinants of prescriptions for respiratory tract infections (RTIs). We conducted a national cross-sectional survey involving primary care paediatricians and parents. Diagnoses and prescriptions made at each consultation were described. Poisson regression models were used to analyse determinants of drug and antibiotic prescriptions for visits due to RTIs. A total of 4,302 physician and parent questionnaires were analysed. These corresponded to 2,151 visits, 792 of which were due to RTIs. Drugs were prescribed in 83.4% of RTI visits, while antibiotics were prescribed in 40.4%. According to paediatricians' perceptions, 84.2% of parents of children with a RTI expected to receive a drug prescription. Paediatricians' perception of parental expectations was the strongest determinant for prescription of drugs and specifically of antibiotics [adjusted relative risk (RR): 1.7 and 3.6, respectively; P decision to prescribe. This study underscores that relational factors, in particular perceived parental expectations, are one of the leading factors of drug prescriptions in paediatric ambulatory care settings, reinforcing the opinion that communication between physicians and parents can affect prescription patterns.

  5. Primary care visit use after positive fecal immunochemical test for colorectal cancer screening.

    Science.gov (United States)

    Hillyer, Grace Clarke; Jensen, Christopher D; Zhao, Wei K; Neugut, Alfred I; Lebwohl, Benjamin; Tiro, Jasmin A; Kushi, Lawrence H; Corley, Douglas A

    2017-10-01

    For some patients, positive cancer screening test results can be a stressful experience that can affect future screening compliance and increase the use of health care services unrelated to medically indicated follow-up. Among 483,216 individuals aged 50 to 75 years who completed a fecal immunochemical test to screen for colorectal cancer at a large integrated health care setting between 2007 and 2011, the authors evaluated whether a positive test was associated with a net change in outpatient primary care visit use within the year after screening. Multivariable regression models were used to evaluate the relationship between test result group and net changes in primary care visits after fecal immunochemical testing. In the year after the fecal immunochemical test, use increased by 0.60 clinic visits for patients with true-positive results. The absolute change in visits was largest (3.00) among individuals with positive test results who were diagnosed with colorectal cancer, but significant small increases also were found for patients treated with polypectomy and who had no neoplasia (0.36) and those with a normal examination and no polypectomy performed (0.17). Groups of patients who demonstrated an increase in net visit use compared with the true-negative group included patients with true-positive results (odds ratio [OR], 1.60; 95% confidence interval [95% CI], 1.54-1.66), and positive groups with a colorectal cancer diagnosis (OR, 7.19; 95% CI, 6.12-8.44), polypectomy/no neoplasia (OR, 1.37; 95% CI, 1.27-1.48), and normal examination/no polypectomy (OR, 1.24; 95% CI, 1.18-1.30). Given the large size of outreach programs, these small changes can cumulatively generate thousands of excess visits and have a substantial impact on total health care use. Therefore, these changes should be included in colorectal cancer screening cost models and their causes investigated further. Cancer 2017;123:3744-3753. © 2017 American Cancer Society. © 2017 American Cancer Society.

  6. Application of Porter's generic strategies in ambulatory health care: a comparison of managerial perceptions in two Israeli sick funds.

    Science.gov (United States)

    Torgovicky, Refael; Goldberg, Avishay; Shvarts, Shifra; Bar Dayan, Yosefa; Onn, Erez; Levi, Yehezkel; BarDayan, Yaron

    2005-01-01

    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.

  7. Association of Structured Virtual Visits for Hypertension Follow-Up in Primary Care with Blood Pressure Control and Use of Clinical Services.

    Science.gov (United States)

    Levine, David Michael; Dixon, Ronald F; Linder, Jeffrey A

    2018-04-23

    Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. "Virtual visits" are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit. To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care. Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences. Primary care patients with hypertension. Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension. Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit. Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140-160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, - 2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, - 0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]). Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.

  8. The demand for ambulatory mental health services from specialty providers.

    Science.gov (United States)

    Horgan, C M

    1986-01-01

    A two-part model is used to examine the demand for ambulatory mental health services in the specialty sector. In the first equation, the probability of having a mental health visit is estimated. In the second part of the model, variations in levels of use expressed in terms of visits and expenditures are examined in turn, with each of these equations conditional on positive utilization of mental health services. In the second part of the model, users are additionally grouped into those with and without out-of-pocket payment for services. This specification accounts for special characteristics regarding the utilization of ambulatory mental health services: (1) a large part of the population does not use these services; (2) of those who use services, the distribution of use is highly skewed; and (3) a large number of users have zero out-of-pocket expenditures. Cost-sharing does indeed matter in the demand for ambulatory mental health services from specialty providers; however, the decision to use mental health services is affected by the level of cost-sharing to a lesser degree than is the decision regarding the level of use of services. The results also show that price is only one of several important factors in determining the demand for services. The lack of significance of family income and of being female is notable. Evidence is presented for the existence of bandwagon effects. The importance of Medicaid in the probability of use equations is noted. PMID:3721874

  9. Assessing local market and organizational readiness for the integration of complementary and alternative medicine into ambulatory care centers.

    Science.gov (United States)

    Makowski, Suzana K E

    2004-01-01

    Complementary and alternative medicine (CAM) is one of the fastest growing segments of the health care industry today, with studies suggesting that between 30% and 50% of the adult population in the United States uses some form of CAM. Many ambulatory care centers are considering integrating CAM into their clinical services. This article will review some of the national trends and present a framework for assessing local market demand for CAM in order to help prioritize an organization's CAM integration strategy.

  10. Family member accompaniment to routine medical visits is associated with better self-care in heart failure patients.

    Science.gov (United States)

    Cené, Crystal W; Haymore, Laura Beth; Lin, Feng-Chang; Laux, Jeffrey; Jones, Christine Delong; Wu, Jia-Rong; DeWalt, Darren; Pignone, Mike; Corbie-Smith, Giselle

    2015-03-01

    To examine the association between frequency of family member accompaniment to medical visits and heart failure (HF) self-care maintenance and management and to determine whether associations are mediated through satisfaction with provider communication. Cross-sectional survey of 150 HF patients seen in outpatient clinics. HF self-care maintenance and management were assessed using the Self-Care of Heart Failure Index. Satisfaction with provider communication was assessed using a single question originally included in the American Board of Internal Medicine Patient Satisfaction Questionnaire. Frequency of family member accompaniment to visits was assessed using a single-item question. We performed regression analyses to examine associations between frequency of accompaniment and outcomes. Mediation analysis was conducted using MacKinnon's criteria. Overall, 61% reported accompaniment by family members to some/most/every visit. Accompaniment to some/most/every visit was associated with higher self-care maintenance (β = 6.4, SE 2.5; p = 0.01) and management (β = 12.7, SE 4.9; p = 0.01) scores. Satisfaction with provider communication may mediate the association between greater frequency of accompaniment to visits and self-care maintenance (1.092; p = 0.06) and self-care management (1.428; p = 0.13). Accompaniment to medical visits is associated with better HF self-care maintenance and management, and this effect may be mediated through satisfaction with provider communication. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

  11. An analysis of risk factors and adverse events in ambulatory surgery

    Directory of Open Access Journals (Sweden)

    Kent C

    2014-06-01

    Full Text Available Christopher Kent, Julia Metzner, Laurent BollagDepartment of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USAAbstract: Care for patients undergoing ambulatory procedures is a broad and expanding area of anesthetic and surgical practice. There were over 35 million ambulatory surgical procedures performed in the US in 2006. Ambulatory procedures are diverse in both type and setting, as they span the range from biopsies performed under local anesthesia to intra-abdominal laparoscopic procedures, and are performed in offices, freestanding ambulatory surgery centers, and ambulatory units of hospitals. The information on adverse events from these varied settings comes largely from retrospective reviews of sources, such as quality-assurance databases and closed malpractice claims. Very few if any ambulatory procedures are emergent, and in comparison to the inpatient population, ambulatory surgical patients are generally healthier. They are still however subject to most of the same types of adverse events as patients undergoing inpatient surgery, albeit at a lower frequency. The only adverse events that could be considered to be unique to ambulatory surgery are those that arise out of the circumstance of discharging a postoperative patient to an environment lacking skilled nursing care. There is limited information on these types of discharge-related adverse events, but the data that are available are reviewed in an attempt to assist the practitioner in patient selection and discharge decision making. Among ambulatory surgical patients, particularly those undergoing screening or cosmetic procedures, expectations from all parties involved are high, and a definition of adverse events can be expanded to include any occurrence that interrupts the rapid throughput of patients or interferes with early discharge and optimal patient satisfaction. This review covers all types of adverse events, but focuses on the more

  12. US National Practice Patterns in Ambulatory Operative Management of Lateral Epicondylitis.

    Science.gov (United States)

    Buller, Leonard T; Best, Matthew J; Nigen, David; Ialenti, Marc; Baraga, Michael G

    2015-12-01

    Lateral epicondylitis is a common cause of elbow pain, frequently responsive to nonoperative management. There are multiple operative techniques for persistently symptomatic patients who have exhausted conservative therapies. Little is known regarding US national trends in operative management of lateral epicondylitis. We conducted a study to investigate changes in use of ambulatory procedures for lateral epicondylitis. Cases of lateral epicondylitis were identified using the National Survey of Ambulatory Surgery and were analyzed for trends in demographics and use of ambulatory surgery. Between 1994 and 2006, the population-adjusted rate of ambulatory surgical procedures increased from 7.29 to 10.44 per 100,000 capita. The sex-adjusted rate of surgery for lateral epicondylitis increased by 85% among females and decreased by 31% among males. Most patients were between ages 40 and 49 years, and the largest percentage increase in age-adjusted rates was found among patients older than 50 years (275%) between 1994 and 2006. Use of regional anesthesia increased from 17% in 1994 to 30% in 2006. Private insurance remained the most common payer. Awareness of the increasing use of ambulatory surgery for lateral epicondylitis may lead to changes in health care policies and positively affect patient care.

  13. An Interactive Ambulatory Nephrology Curriculum for Internal Medicine Interns: Design, Implementation, and Participant Feedback.

    Science.gov (United States)

    Gomez, Alexis C; Warburton, Karen M; Miller, Rachel K; Negoianu, Dan; Cohen, Jordana B

    2017-09-01

    While diminishing nephrology fellow recruitment is a known issue, more work is needed to evaluate possible interventions to reverse this trend. We designed and implemented a curriculum to increase exposure to ambulatory nephrology among internal medicine interns. The curriculum focused on key aspects of outpatient nephrology practice, including supervised clinic visits, formal themed didactic content, and an online interactive forum with assigned evidence-based readings and small-group responses to relevant cases. We obtained postcourse surveys from all participating interns. Of the 43 interns who took part in the first year of the ambulatory nephrology curriculum, 100% reported a positive didactic experience and 91% reported a positive interactive online experience. 77% reported an improvement in their familiarity with clinical nephrology practice (median 2-point increase in familiarity score on a 7-point scale, P<0.001 by signed rank testing). Qualitative feedback included praise for the high-yield topics covered by the lectures and energizing teachers. In conclusion, we successfully implemented an ambulatory nephrology curriculum using a framework that integrated formal didactics, interactive online learning, and key clinical components of outpatient nephrology care. Future investigation will evaluate whether early implementation of this curriculum is associated with increased pursuit of nephrology as a career. Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

  14. Non-EEG based ambulatory seizure detection designed for home use : What is available and how will it influence epilepsy care?

    NARCIS (Netherlands)

    van Andel, Judith; Thijs, Roland D.; de Weerd, Al; Arends, Johan; Leijten, Frans

    OBJECTIVE: This study aimed to (1) evaluate available systems and algorithms for ambulatory automatic seizure detection and (2) discuss benefits and disadvantages of seizure detection in epilepsy care. METHODS: PubMed and EMBASE were searched up to November 2014, using variations and synonyms of

  15. Providing Cardiology Care in Rural Areas Through Visiting Consultant Clinics.

    Science.gov (United States)

    Gruca, Thomas S; Pyo, Tae-Hyung; Nelson, Gregory C

    2016-06-30

    Workforce experts predict a future shortage of cardiologists that is expected to impact rural areas more severely than urban areas. However, there is little research on how rural patients are currently served through clinical outreach. This study examines the impact of cardiology outreach in Iowa, a state with a large rural population, on participating cardiologists and on patient access. Outreach clinics are tracked annually in the Office of Statewide Clinical Education Programs Visiting Medical Consultant Database (University of Iowa Carver College of Medicine). Data from 2014 were analyzed. In 2014, an estimated 5460 visiting consultant clinic days were provided in 96 predominantly rural cities by 167 cardiologists from Iowa and adjoining states. Forty-five percent of Iowa cardiologists participated in rural outreach. Visiting cardiologists from Iowa and adjoining states drive an estimated 45 000 miles per month. Because of monthly outreach clinics, the average driving time to the nearest cardiologist falls from 42.2±20.0 to 14.7±11.0 minutes for rural Iowans. Cardiology outreach improves geographic access to office-based cardiology care for more than 1 million Iowans out of a total population of 3 million. Direct travel costs and opportunity costs associated with physician travel are estimated to be more than $2.1 million per year. Cardiologists in Iowa and adjoining states have expanded access to office-based cardiology care from 18 to 89 of the 99 counties in Iowa. In these 71 counties without a full-time cardiologist, visiting consultant clinics can accommodate more than 50% of office visits in the patients' home county. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

  16. Medical condition and care of undocumented migrants in ambulatory clinics in Tel Aviv, Israel: assessing unmet needs.

    Science.gov (United States)

    Mor, Zohar; Raveh, Yuval; Lurie, Ido; Leventhal, Alex; Gamzu, Roni; Davidovitch, Nadav; Benari, Orel; Grotto, Itamar

    2017-07-14

    Approximately 150,000 undocumented migrants (UM) who are medically uninsured reside in Israel, including ~50,000 originating from the horn of Africa (MHA). Free medical-care is provided by two walk-in clinics in Tel-Aviv. This study aims to compare the medical complaints of UM from different origins, define their community health needs and assess gaps between medical needs and available services. This cross-sectional study included a random sample of 610 UM aged 18-64 years, who were treated in these community clinics between 2008 and 2011. The study compared UM who had complex medical conditions which necessitated referral to more equipped medical settings with UM having mild/simple medical conditions, who were treated at the clinics. MHA were younger, unemployed and more commonly males compared with UM originating from other countries. MHA also had longer referral-delays and visited the clinics less frequently. UM with complex medical conditions were more commonly females, had chronic diseases and demonstrated longer referral-delays than those who had mild/simple medical conditions. The latter more commonly presented with complained of respiratory, muscular and skeletal discomfort. In multivariate analysis, the variables which predicted complex medical conditions included female gender, chronic illnes and self-referral to the clinics. The ambulatory clinics were capable of responding to mild/simple medical conditions. Yet, the health needs of women and migrants suffering from complex medical conditions and chronic diseases necessitated referrals to secondary/tertiary medical settings, while jeopardizing the continuity of care. The health gaps can be addressed by a more holistic social approach, which includes integration of UM in universal health insurance.

  17. The contribution of viral hepatitis to the burden of chronic liver disease in the United States.

    Science.gov (United States)

    Roberts, Henry W; Utuama, Ovie A; Klevens, Monina; Teshale, Eyasu; Hughes, Elizabeth; Jiles, Ruth

    2014-03-01

    Chronic liver disease (CLD) is increasingly recognized as a major public health problem. However, in the United States, there are few nationally representative data on the contribution of viral hepatitis as an etiology of CLD. We applied a previously used International Classification of Diseases, Ninth Revision, Clinical Modification-based definition of CLD cases to the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey databases for 2006-2010. We estimated the mean number of CLD visits per year, prevalence ratio of visits by patient characteristics, and the percentage of CLD visits attributed to viral hepatitis and other selected etiologies. An estimated 6.0 billion ambulatory care visits occurred in the United States from 2006 to 2010, of which an estimated 25.8 million (0.43%) were CLD-related. Among adults aged 45-64 years, Medicaid and Medicare recipients were 3.9 (prevalence ratio (PR)=3.9, 95% confidence limit (CL; 2.8, 5.4)) and 2.3 (PR=2.3, 95% CL (1.6, 3.4)) times more likely to have a CLD-related ambulatory visit than those with private insurance, respectively. In the United States, from 2006 to 2010, an estimated 49.6% of all CLD-related ambulatory visits were attributed solely to viral hepatitis B and C diagnoses. In this unique application of health-care utilization data, we confirm that viral hepatitis is an important etiology of CLD in the United States, with hepatitis B and C contributing approximately one-half of the CLD burden. CLD ambulatory visits in the United States disproportionately occur among adults, aged 45-64 years, who are primarily minorities, men, and Medicare or Medicaid recipients.

  18. Office-Based Tools and Primary Care Visit Communication, Length, and Preventive Service Delivery.

    Science.gov (United States)

    Lafata, Jennifer Elston; Shay, L Aubree; Brown, Richard; Street, Richard L

    2016-04-01

    The use of physician office-based tools such as electronic health records (EHRs), health risk appraisal (HRA) instruments, and written patient reminder lists is encouraged to support efficient, high-quality, patient-centered care. We evaluate the association of exam room use of EHRs, HRA instruments, and self-generated written patient reminder lists with patient-physician communication behaviors, recommended preventive health service delivery, and visit length. Observational study of 485 office visits with 64 primary care physicians practicing in a health system serving the Detroit metropolitan area. Study data were obtained from patient surveys, direct observation, office visit audio-recordings, and automated health system records. Outcome measures included visit length in minutes, patient use of active communication behaviors, physician use of supportive talk and partnership-building communication behaviors, and percentage of delivered guideline-recommended preventive health services for which patients are eligible and due. Simultaneous linear regression models were used to evaluate associations between tool use and outcomes. Adjusted models controlled for patient characteristics, physician characteristics, characteristics of the relationship between the patient and physician, and characteristics of the environment in which the visit took place. Prior to adjusting for other factors, visits in which the EHR was used on average were significantly (p communication behaviors facilitating patient involvement (2.1 vs. 2.6 occurrences), but more use of active patient communication behaviors (4.4 vs. 2.6). Likewise, HRA use was significantly associated with increased preventive services delivery (62.1 percent vs. 57.0 percent). All relationships remained significant (p > .05) in adjusted models with the exception of that between HRA use and preventive service delivery. Office-based tools intended to facilitate the implementation of desired primary care practice

  19. Interior design for ambulatory care facilities: how to reduce stress and anxiety in patients and families.

    Science.gov (United States)

    Frasca-Beaulieu, K

    1999-01-01

    The following article illustrates some important factors to consider when designing ambulatory care facilities (ACFs), and focuses on how wayfinding, noise control, privacy, security, color and lighting, general ambience, textures, and nature can have a profound influence on patient and family stress, consumer satisfaction, health and well-being. Other important design issues: convenience and accessibility, accommodation to various populations, consumer and family focus, patient education, image, as well as current equipment needs and future growth are examined in light of the prevailing trends in health care delivery. In sum, this feature explores the important stress-reducing and health-promoting elements involved in successful ACF design.

  20. From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care.

    Science.gov (United States)

    Wilf-Miron, R; Lewenhoff, I; Benyamini, Z; Aviram, A

    2003-02-01

    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 possibilities for organisational learning. Reporting physicians were granted immunity, which encouraged open reporting of errors. A telephone "hotline" served the medical staff for direct reporting and receipt of emotional support and medical guidance. Any adverse event which had learning potential was debriefed, while focusing on the human cause of error within a systemic context. Specific recommendations were formulated to rectify processes conducive to error when failures were identified. During the first 5 years of implementation, the aviation safety concept and tools were successfully adapted to ambulatory care, fostering a culture of greater concern for patient safety through risk management while providing support to the medical staff.

  1. A missed primary care appointment correlates with a subsequent emergency department visit among children with asthma.

    Science.gov (United States)

    McGovern, Colleen Marie; Redmond, Margaret; Arcoleo, Kimberly; Stukus, David R

    2017-11-01

    Since the Affordable Care Act's implementation, emergency department (ED) visits have increased. Poor asthma control increases the risk of acute exacerbations and preventable ED visits. The Centers for Medicare and Medicaid Services support the reduction of preventable ED visits to reduce healthcare spending. Implementation of interventions to avoid preventable ED visits has become a priority for many healthcare systems yet little data exist examining children's missed asthma management primary care (PC) appointments and subsequent ED visits. Longitudinal, retrospective review at a children's hospital was conducted for children with diagnosed asthma (ICD-9 493.xx), ages 2-18 years, scheduled for a PC visit between January 1, 2010, and June 30, 2012 (N = 3895). Records were cross-referenced with all asthma-related ED visits from January 1, 2010 to December 31, 2012. Logistic regression with maximum likelihood estimation was conducted. None of the children who completed a PC appointment experienced an ED visit in the subsequent 6 months whereas 2.7% of those with missed PC appointments had an ED visit (χ 2 = 64.28, p asthma as one mechanism for preventing ED visits was demonstrated. Interventions targeting missed visits could decrease asthma-related morbidity, preventable ED visits, and healthcare costs.

  2. Monthly variation in pediatric visits for headache to US emergency departments.

    Science.gov (United States)

    Caperell, Kerry; Rominger, Anna

    2017-08-01

    Headache is a common pediatric symptom often associated with stress and fatigue which may be more common during the school year. The purpose of this study is to determine if visits for headache are more common during the months of the school year. This study is a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) database from 2001 to 2010. Patient visits in those aged 18 years or younger not associated with injury were examined. Only visits with an International Classification of Diseases, ninth revision (ICD-9) code consistent with headache were included. Data were analyzed using cumulative binomial probabilities. This statistic was used to establish the chance of seeing up to the observed number of visits for headache in a given month assuming that all months have an equal number of visits. A total of 660 unweighted visits representing 3.2 million patient encounters met the inclusion and exclusion criteria. Visits for headache were more common during the months of January, September, and October and less common in March, April, July, and November. Subgroup analysis was performed for children aged 13-18 years. In this subgroup, headaches were more common in January, September, and October. They were less common in July and December. Headache is more common during the first 2 months back to school in the fall as well as after the winter break in January. While we are not able to establish causality, we propose that children with headache require additional attention during the school year, particularly in the months following summer and winter breaks. Copyright © 2017 American Federation for Medical Research.

  3. Statewide Policy Change in Pediatric Dental Care, and the Impact on Pediatric Dental and Physician Visits.

    Science.gov (United States)

    Zlotnick, Cheryl; Tam, Tammy; Ye, Yu

    2017-10-01

    Introduction In 2007, the California signed legislation mandating a dental visit for all children entering kindergarten or first grade; no such mandate was made for physician visits. This study examines the impact of this policy change on the risk factors associated with obtaining pediatric dental and physician health care visits. Methods Every 2 years, California Health Interview Survey conducts a statewide survey on a representative community sample. This cross-sectional study took advantage of these data to conduct a "natural experiment" assessing the impact of this policy change on both pediatric physician and dental care visits in the past year. Samples included surveys of adults and children (ages 5-11) on years 2005 (n = 5096), 2007 (n = 4324) and 2009 (n = 4100). Results Although few changes in risk factors were noted in pediatric physician visits, a gradual decrease in risk factors was found in pediatric dental visits from 2005 to 2009. Report of no dental visit was less likely for: younger children (OR -0.81, CI 0.75-0.88), insured children (OR 0.34, CI 0.22-0.53), and children who had a physician's visit last year (OR 0.37, CI 0.25-0.53) in 2005. By 2007, absence of insurance was the only risk factor related to having no dental visit (OR 0.34, CI 0.19-0.61). By 2009, no a priori measured risk factors were associated with not having a dental visit for children aged 5-11 years. Conclusions A statewide policy mandating pediatric dental visits appears to have reduced disparities. A policy for medical care may contribute to similar benefits.

  4. Perspectives on ambulatory anesthesia: the patient’s point of view

    Directory of Open Access Journals (Sweden)

    Sehmbi H

    2014-12-01

    Full Text Available Herman Sehmbi, Jean Wong, David T WongDepartment of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, CanadaAbstract: Recent advances in anesthetic and surgical techniques have led to tremendous growth of ambulatory surgery. With patients with many co-morbid conditions undergoing complex procedures in an ambulatory setting, the challenges in providing ambulatory surgery and anesthesia are immense. In recent years, the paradigm has shifted from a health-care provider focus involving process compliance and clinical outcomes, to a patient-centered strategy that includes patients’ perspectives of desired outcomes. Improving preoperative patient education while reducing unnecessary testing, improving postoperative pain management, and reducing postoperative nausea and vomiting may help enhance patient satisfaction. The functional status of most patients is reduced postoperatively, and thus the pattern of recovery is an area of ongoing research. Standardized and validated psychometric questionnaires such as Quality of Recovery-40 and Postoperative Quality of Recovery Scale are potential tools to assess this. Patient satisfaction has been identified as an important outcome measure and dedicated tools to assess this in various clinical settings are needed. Identification of key aspects of ambulatory surgery deemed important from patients’ perspectives, and implementation of validated outcome questionnaires, are important in improving patient centered care and patient satisfaction.Keywords: ambulatory, patient, satisfaction, anesthesia, outcomes, questionnaire, perspectives

  5. Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting.

    Science.gov (United States)

    Vadivelu, Nalini; Kai, Alice M; Kodumudi, Vijay; Berger, Jack M

    2016-01-01

    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.

  6. Management of comorbidities in ambulatory anesthesia: a review

    Directory of Open Access Journals (Sweden)

    Dabu-Bondoc S

    2015-06-01

    Full Text Available Susan Dabu-Bondoc, Kirk Shelley Department of Anesthesiology, School of Medicine, Yale University, New Haven, CT, USAAbstract: Advances in medical science now allow people with significant medical issues to live at home. As the outpatient population ages and surgical techniques advance, the ambulatory anesthesiologist has to be prepared to handle these “walking wounded”. The days of restricting ambulatory surgery procedures to American Society of Anesthesiologists class 1 and 2 patients are rapidly fading into the past. To remain competitive and economically viable, the modern ambulatory surgery center needs to expand its practice to include patients with medical comorbidities. In an environment where production and economic pressures exist, maintaining safety and good outcomes in high-risk patients for ambulatory surgery can be arduous. Adding to the complexity of this challenge is the rapid evolution of the therapeutic approaches to a variety of medical issues. For example, there has been a significant increase in the number and types of insulin a diabetic patient might be prescribed in recent years. In the case of the patient with coronary artery disease, the variety of both drug and nondrug eluding stents or new antithrombotic agents has also increased the complexity of perioperative management. Complex patients need careful, timely, and team-based preoperative evaluation by an anesthesia provider who is knowledgeable of outpatient care. Optimizing comorbidities preoperatively is a crucial initial step in minimizing risk. This paper will examine a number of common medical issues and explore their impact on managing outpatient surgical procedures.Keywords: ambulatory surgery, medical comorbidities, diabetes, coronary artery disease, respiratory disease, obesity

  7. Improving newborn care practices through home visits: lessons from Malawi, Nepal, Bangladesh, and Uganda

    Directory of Open Access Journals (Sweden)

    Deborah Sitrin

    2015-03-01

    Full Text Available Background: Nearly all newborn deaths occur in low- or middle-income countries. Many of these deaths could be prevented through promotion and provision of newborn care practices such as thermal care, early and exclusive breastfeeding, and hygienic cord care. Home visit programmes promoting these practices were piloted in Malawi, Nepal, Bangladesh, and Uganda. Objective: This study assessed changes in selected newborn care practices over time in pilot programme areas in four countries and evaluated whether women who received home visits during pregnancy were more likely to report use of three key practices. Design: Using data from cross-sectional surveys of women with live births at baseline and endline, the Pearson chi-squared test was used to assess changes over time. Generalised linear models were used to assess the relationship between the main independent variable – home visit from a community health worker (CHW during pregnancy (0, 1–2, 3+ – and use of selected practices while controlling for antenatal care, place of delivery, and maternal age and education. Results: There were statistically significant improvements in practices, except applying nothing to the cord in Malawi and early initiation of breastfeeding in Bangladesh. In Malawi, Nepal, and Bangladesh, women who were visited by a CHW three or more times during pregnancy were more likely to report use of selected practices. Women who delivered in a facility were also more likely to report use of selected practices in Malawi, Nepal, and Uganda; association with place of birth was not examined in Bangladesh because only women who delivered outside a facility were asked about these practices. Conclusion: Home visits can play a role in improving practices in different settings. Multiple interactions are needed, so programmes need to investigate the most appropriate and efficient ways to reach families and promote newborn care practices. Meanwhile, programmes must take advantage of

  8. Time is up: increasing shadow price of time in primary-care office visits.

    Science.gov (United States)

    Tai-Seale, Ming; McGuire, Thomas

    2012-04-01

    A physician's own time is a scarce resource in primary care, and the physician must constantly evaluate the gain from spending more time with the current patient against moving to address the health-care needs of the next. We formulate and test two alternative hypotheses. The first hypothesis is based on the premise that with time so scarce, physicians equalize the marginal value of time across patients. The second, alternative hypothesis states that physicians allocate the same time to each patient, regardless of how much the patient benefits from the time at the margin. For our empirical work, we examine the presence of a sharply increasing subjective shadow price of time around the 'target' time using video recordings of 385 visits by elderly patients to their primary care physician. We structure the data at the 'topic' level and find evidence consistent with the alternative hypothesis. Specifically, time elapsed within a visit is a very strong determinant of the current topic being the 'last topic'. This finding implies the physician's shadow price of time is rising during the course of a visit. We consider whether dislodging a target-time mentality from physicians (and patients) might contribute to more productive primary care practice. Copyright © 2011 John Wiley & Sons, Ltd.

  9. Utilization of lean management principles in the ambulatory clinic setting.

    Science.gov (United States)

    Casey, Jessica T; Brinton, Thomas S; Gonzalez, Chris M

    2009-03-01

    The principles of 'lean management' have permeated many sectors of today's business world, secondary to the success of the Toyota Production System. This management method enables workers to eliminate mistakes, reduce delays, lower costs, and improve the overall quality of the product or service they deliver. These lean management principles can be applied to health care. Their implementation within the ambulatory care setting is predicated on the continuous identification and elimination of waste within the process. The key concepts of flow time, inventory and throughput are utilized to improve the flow of patients through the clinic, and to identify points that slow this process -- so-called bottlenecks. Nonessential activities are shifted away from bottlenecks (i.e. the physician), and extra work capacity is generated from existing resources, rather than being added. The additional work capacity facilitates a more efficient response to variability, which in turn results in cost savings, more time for the physician to interact with patients, and faster completion of patient visits. Finally, application of the lean management principle of 'just-in-time' management can eliminate excess clinic inventory, better synchronize office supply with patient demand, and reduce costs.

  10. Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care.

    Science.gov (United States)

    Finnegan, Micaela A; Shaffer, Robyn; Remington, Austin; Kwong, Jereen; Curtin, Catherine; Hernandez-Boussard, Tina

    2017-06-21

    Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure. We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge. Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  11. Effectiveness of transmucosal sedation for special needs populations in the ambulatory care setting.

    Science.gov (United States)

    Tetef, Sue

    2014-12-01

    Transmucosal is an alternative route for administering medications (ie, dexmedetomidine, midazolam, naloxone) that can be effective for procedural or moderate sedation in patients with special needs when other routes are not practical or are contraindicated. Special needs populations include children, older adults, pregnant and breast-feeding women, and people with disabilities or conditions that limit their ability to function and cope. Understanding the perioperative nurse's role in the care of patients receiving medications via the transmucosal route can lead to better clinical outcomes. Successful use of the transmucosal route requires knowledge of when to administer a medication, how often and how much of a medication should be administered, the onset and duration of action, the adverse effects or contraindications, and the key benefits. In addition, a case study approach suggests that transmucosal sedation can decrease patient stress and anxiety related to undergoing medical procedures or surgery in the ambulatory care setting. Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.

  12. The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions

    Science.gov (United States)

    Bakal, Jeffrey A.; Green, Lee; Bahler, Brad; Lewanczuk, Richard

    2018-01-01

    BACKGROUND: Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care. METHODS: We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months. RESULTS: Adults receiving care within a primary care network (n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care (n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96–0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93–0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03–1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07–1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years. INTERPRETATION: Care within a primary care network was associated with fewer emergency department visits and fewer hospital days. PMID:29530868

  13. Impact of the ABCDE triage in primary care emergency department on the number of patient visits to different parts of the health care system in Espoo City

    Directory of Open Access Journals (Sweden)

    Kantonen Jarmo

    2012-01-01

    Full Text Available Abstract Background Many Finnish emergency departments (ED serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland. Methods The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital. A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care, B (to be examined within 10 min, C (to be examined within 1 h, D (to be examined within 2 h and E (no need for immediate treatment for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse. The introduction of this triage system was combined with information to the public on the "correct" use of emergency services. Results After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month as compared to the three previous years in the EDs

  14. The Home Care Crew Scheduling Problem: Preference-based visit clustering and temporal dependencies

    DEFF Research Database (Denmark)

    Rasmussen, Matias Sevel; Justesen, Tor Fog; Dohn, Anders Høeg

    2012-01-01

    In the Home Care Crew Scheduling Problem a staff of home carers has to be assigned a number of visits to patients’ homes, such that the overall service level is maximised. The problem is a generalisation of the vehicle routing problem with time windows. Required travel time between visits and time...... preference constraints. The algorithm is tested both on real-life problem instances and on generated test instances inspired by realistic settings. The use of the specialised branching scheme on real-life problems is novel. The visit clustering decreases run times significantly, and only gives a loss...... windows of the visits must be respected. The challenge when assigning visits to home carers lies in the existence of soft preference constraints and in temporal dependencies between the start times of visits.We model the problem as a set partitioning problem with side constraints and develop an exact...

  15. Patient satisfaction with ambulatory care in Germany: effects of patient- and medical practice-related factors.

    Science.gov (United States)

    Auras, Silke; Ostermann, Thomas; de Cruppé, Werner; Bitzer, Eva-Maria; Diel, Franziska; Geraedts, Max

    2016-12-01

    The study aimed to illustrate the effect of the patients' sex, age, self-rated health and medical practice specialization on patient satisfaction. Secondary analysis of patient survey data using multilevel analysis (generalized linear mixed model, medical practice as random effect) using a sequential modelling strategy. We examined the effects of the patients' sex, age, self-rated health and medical practice specialization on four patient satisfaction dimensions: medical practice organization, information, interaction, professional competence. The study was performed in 92 German medical practices providing ambulatory care in general medicine, internal medicine or gynaecology. In total, 9888 adult patients participated in a patient survey using the validated 'questionnaire on satisfaction with ambulatory care-quality from the patient perspective [ZAP]'. We calculated four models for each satisfaction dimension, revealing regression coefficients with 95% confidence intervals (CIs) for all independent variables, and using Wald Chi-Square statistic for each modelling step (model validity) and LR-Tests to compare the models of each step with the previous model. The patients' sex and age had a weak effect (maximum regression coefficient 1.09, CI 0.39; 1.80), and the patients' self-rated health had the strongest positive effect (maximum regression coefficient 7.66, CI 6.69; 8.63) on satisfaction ratings. The effect of medical practice specialization was heterogeneous. All factors studied, specifically the patients' self-rated health, affected patient satisfaction. Adjustment should always be considered because it improves the comparability of patient satisfaction in medical practices with atypically varying patient populations and increases the acceptance of comparisons. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

  16. Use of continuous ambulatory infusions of concentrated subcutaneous (s.q.) hydromorphone versus intravenous (i.v.) morphine: cost implications for palliative care.

    Science.gov (United States)

    Fudin, J; Smith, H S; Toledo-Binette, C S; Kenney, E; Yu, A B; Boutin, R

    2000-01-01

    Health care practitioners are increasingly under pressure to curtail spending while trying to deliver excellent patient care. These issues are also affecting palliative care, particularly now that palliative care programs are expanding. A comparison of cost-effectiveness and feasibility of using continuous subcutaneous (s.q.) ambulatory infusion of hydromorphone versus intravenous (i.v.) ambulatory morphine is illustrated in this study. With the high doses of morphine required in chronic cancer pain, the use of subcutaneous morphine is not feasible due to the volume of solution required to be delivered. Hydromorphone can be prepared in concentrated solutions enabling it to be delivered by the subcutaneous route. Morphine stability data are available. However, hydromorphone stability has only been verified for seven days; thus, stability data were needed post-seven days. Concentrations of 10 mg/ml, 20 mg/ml, 50 mg/ml, and 100 mg/ml, in 0.9 percent normal saline or dextrose 5 percent water, were analyzed via high-performance liquid chromatography (HPLC) at seven and 28 days. Cost comparisons of supplies and associated costs with subcutaneous versus intravenous solutions were obtained. Hydromorphone was found to be stable for 28 days in both dilutants. Cost analysis of a hydromorphone 28-day supply resulted in substantial savings over the equivalent costs of morphine infusions.

  17. Hospitalization for uncomplicated hypertension: an ambulatory care sensitive condition.

    Science.gov (United States)

    Walker, Robin L; Chen, Guanmin; McAlister, Finlay A; Campbell, Norm R C; Hemmelgarn, Brenda R; Dixon, Elijah; Ghali, William; Rabi, Doreen; Tu, Karen; Jette, Nathalie; Quan, Hude

    2013-11-01

    Hospitalizations for ambulatory care sensitive conditions (ACSC) represent an indirect measure of access and quality of community care. This study explored hospitalization rates for 1 ACSC, uncomplicated hypertension, and the factors associated with hospitalization. A cohort of patients with incident hypertension, and their covariates, was defined using validated case definitions applied to International Classification of Disease administrative health data in 4 Canadian provinces between fiscal years 1997 and 2004. We applied the Canadian Institute for Health Information's case definition to detect all patients who had an ACSC hospitalization for uncomplicated hypertension. We employed logistic regression to assess factors associated with an ACSC hospitalization for uncomplicated hypertension. The overall rate of hospitalizations for uncomplicated hypertension in the 4 provinces was 3.7 per 1000 hypertensive patients. The risk-adjusted rate was lowest among those in an urban setting (2.6 per 1000; 95% confidence interval [CI], 2.3-2.7), the highest income quintile (3.4 per 1000; 95% CI, 2.8-4.2), and those with no comorbidities (3.6 per 1000; 95% CI, 3.2-3.9). Overall, Newfoundland had the highest adjusted rate (5.7 per 1000; 95% CI, 4.9-6.7), and British Columbia had the lowest (3.7 per 1000; 95% CI, 3.4-4.2). The adjusted rate declined from 5.9 per 1000 in 1997 to 3.7 per 1000 in 2004. We found that the rate of hospitalizations for uncomplicated hypertension has decreased over time, which might reflect improvements in community care. Geographic variations in the rate of hospitalizations indicate disparity among the provinces and those residing in rural regions. Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

  18. Association of ambient air pollution and meteorological factors with primary care visits at night due to asthma attack.

    Science.gov (United States)

    Yamazaki, Shin; Shima, Masayuki; Yoda, Yoshiko; Oka, Katsumi; Kurosaka, Fumitake; Shimizu, Shigeta; Takahashi, Hironobu; Nakatani, Yuji; Nishikawa, Jittoku; Fujiwara, Katsuhiko; Mizumori, Yasuyuki; Mogami, Akira; Yamada, Taku; Yamamoto, Nobuharu

    2013-09-01

    The association of outdoor air pollution and meteorological elements with primary care visits at night due to asthma attack was studied. A case-crossover study was conducted in a primary care clinic in Himeji City, Japan. The subjects were 956 children aged 0-14 years who visited the clinic with an asthma attack between the hours of 9 p.m. and 6 a.m. Daily concentrations of particulate matter, ozone, nitrogen dioxide, and a number of meteorological elements were measured, and a conditional logistic regression model was used to estimate odds ratios (ORs) of primary care visits per unit increment of air pollutants or meteorological elements. The analyses took into consideration the effects of seasonality. Of the 956 children, 73 (7.6 %) were aged asthma attack at night in the spring or summer was found. An inverse relation between suspended particulate matter and primary care visits due to asthma attack was detected in the winter. ORs in the summer per degree increment in daily mean temperature was 1.31 [95 % confidential interval (CI) 1.09-1.56], and ORs in the autumn per hourly increment in daily hours of sunshine was 0.94 (95 % CI 0.90-0.99). The findings of our study fail to support any association between daily mean concentration of air pollutant and primary care visits at night. However, we did find evidence indicating that certain meteorological elements may be associated with primary care visits.

  19. Older depressed Latinos' experiences with primary care visits for personal, emotional and/or mental health problems: a qualitative analysis.

    Science.gov (United States)

    Izquierdo, Adriana; Sarkisian, Catherine; Ryan, Gery; Wells, Kenneth B; Miranda, Jeanne

    2014-01-01

    To describe salient experiences with a primary care visit (eg, the context leading up to the visit, the experience and/or outcomes of that visit) for emotional, personal and/or mental health problems older Latinos with a history of depression and recent depressive symptoms and/or antidepressant medication use reported 10 years after enrollment into a randomized controlled trial of quality-improvement for depression in primary care. Secondary analysis of existing qualitative data from the second stage of the continuation study of Partners in Care (PIC). Latino ethnicity, aged > or =50 years, recent depressive symptoms and/or antidepressant medication use, and a recent primary care visit for mental health problems. Of 280 second-stage participants, 47 were eligible. Both stages of the continuation study included participants from the PIC parent study control and 2 intervention groups, and all had a history of depression. Data analyzed by a multidisciplinary team using grounded theory methodology. Five themes were identified: beliefs about the nature of depression; prior experiences with mental health disorders/treatments; sociocultural context (eg, social relationships, caregiving, the media); clinic-related features (eg, accessibility of providers, staff continuity, amount of visit time); and provider attributes (eg, interpersonal skills, holistic care approach). Findings emphasize the importance of key features for shaping the context leading up to primary care visits for help-seeking for mental health problems, and the experience and/or outcomes of those visits, among older depressed Latinos at long-term follow-up, and may help tailor chronic depression care for the clinical management of this vulnerable population.

  20. "My Favourite Day Is Sunday": Community Perceptions of (Drug-Resistant Tuberculosis and Ambulatory Tuberculosis Care in Kara Suu District, Osh Province, Kyrgyzstan.

    Directory of Open Access Journals (Sweden)

    Doris Burtscher

    Full Text Available Kyrgyzstan is one of the 27 high multidrug-resistant tuberculosis (MDR-TB burden countries listed by the WHO. In 2012, Médecins Sans Frontières (MSF started a drug-resistant tuberculosis (DR-TB project in Kara Suu District. A qualitative study was undertaken to understand the perception of TB and DR-TB in order to improve the effectiveness and acceptance of the MSF intervention and to support advocacy strategies for an ambulatory model of care.This paper reports findings from 63 interviews with patients, caregivers, health care providers and members of communities. Data was analysed using a qualitative content analysis. Validation was ensured by triangulation and a 'thick' description of the research context, and by presenting deviant cases.Findings show that the general population interprets TB as the 'lungs having a cold' or as a 'family disease' rather than as an infectious illness. From their perspective, individuals facing poor living conditions are more likely to get TB than wealthier people. Vulnerable groups such as drug and alcohol users, homeless persons, ethnic minorities and young women face barriers in accessing health care. As also reported in other publications, TB is highly stigmatised and possible side effects of the long treatment course are seen as unbearable; therefore, people only turn to public health care quite late. Most patients prefer ambulatory treatment because of the much needed emotional support from their social environment, which positively impacts treatment concordance. Health care providers favour inpatient treatment only for a better monitoring of side effects. Health staff increasingly acknowledges the central role they play in supporting DR-TB patients, and the importance of assuming a more empathic attitude.Health promotion activities should aim at improving knowledge on TB and DR-TB, reducing stigma, and fostering the inclusion of vulnerable populations. Health seeking delays and adherence problems will

  1. Challenges to Safe Injection Practices in Ambulatory Care.

    Science.gov (United States)

    Anderson, Laura; Weissburg, Benjamin; Rogers, Kelli; Musuuza, Jackson; Safdar, Nasia; Shirley, Daniel

    2017-05-01

    Most recent infection outbreaks caused by unsafe injection practices in the United States have occurred in ambulatory settings. We utilized direct observation and a survey to assess injection practices at 31 clinics. Improper vial use was observed at 13 clinics (41.9%). Pharmacy support and healthcare worker education may improve injection practices. Infect Control Hosp Epidemiol 2017;38:614-616.

  2. [Travel times of patients to ambulatory care physicians in Germany].

    Science.gov (United States)

    Schang, Laura; Kopetsch, Thomas; Sundmacher, Leonie

    2017-12-01

    The time needed by patients to get to a doctor's office represents an important indicator of realised access to care. In Germany, findings on travel times are only available from surveys or for some regions. For the first time, this study examines nationwide and physician group-specific travel times in the ambulatory care sector in Germany and describes demographic, supply-side and spatial determinants of variations. Using a full review of patient consultations in the statutory health insurance system from 2009/2010 for 14 physician groups (approximately 518 million cases), case-related travel times by car between patients' places of residence and physician's practices were estimated at the municipal level. Physicians were reached in less than 30 min in 90.8% of cases for primary care physicians and up to 63% of cases for radiologists. Patients between 18 and under 30 years of age travel longer to get to the doctor than other age groups. The average travel time at the county level systematically differs between urban and rural planning areas. In the case of gynecologists, dermatologists and ophthalmologists, the average journey time decreases with increasing physician density at the county level, but remains approximately constant from a recognisable point of inflection. There is no association between primary care physician density and travel time at the district level. Spatial analyses show physician group-specific patterns of regional concentrations with an increased proportion of cases with very long travel times. Patients' travel times are influenced by supply- and demand-side determinants. Interactions between influential determinants should be analysed in depth to examine the extent to which the time travelled is an expression of regional under- or over-supply rather than an expression of patient preferences.

  3. From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care

    Science.gov (United States)

    Wilf-Miron, R; Lewenhoff, I; Benyamini, Z; Aviram, A

    2003-01-01

    

 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 possibilities for organisational learning. Reporting physicians were granted immunity, which encouraged open reporting of errors. A telephone "hotline" served the medical staff for direct reporting and receipt of emotional support and medical guidance. Any adverse event which had learning potential was debriefed, while focusing on the human cause of error within a systemic context. Specific recommendations were formulated to rectify processes conducive to error when failures were identified. During the first 5 years of implementation, the aviation safety concept and tools were successfully adapted to ambulatory care, fostering a culture of greater concern for patient safety through risk management while providing support to the medical staff. PMID:12571343

  4. Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review.

    Science.gov (United States)

    DiMartino, Lisa D; Weiner, Bryan J; Mayer, Deborah K; Jackson, George L; Biddle, Andrea K

    2014-12-01

    Frequent emergency department (ED) visits are an indicator of poor quality of cancer care. Coordination of care through the use of palliative care teams may limit aggressive care and improve outcomes for patients with cancer at the end of life. To systematically review the literature to determine whether palliative care interventions implemented in the hospital, home, or outpatient clinic are more effective than usual care in reducing ED visits among patients with cancer at the end of life. PubMed, EMBASE, and CINAHL databases were searched from database inception to May 7, 2014. Only randomized/non-randomized controlled trials (RCTs) and observational studies examining the effect of palliative care interventions on ED visits among adult patients with cancer with advanced disease were considered. Data were abstracted from the articles that met all the inclusion criteria. A second reviewer independently abstracted data from 2 articles and discrepancies were resolved. From 464 abstracts, 2 RCTs, 10 observational studies, and 1 non-RCT/quasi-experimental study were included. Overall there is limited evidence to support the use of palliative care interventions to reduce ED visits, although studies examining effect of hospice care and those conducted outside of the United States reported a statistically significant reduction in ED visits. Evidence regarding whether palliative care interventions implemented in the hospital, home or outpatient clinic are more effective than usual care at reducing ED visits is not strongly substantiated based on the literature reviewed. Improvements in the quality of reporting for studies examining the effect of palliative care interventions on ED use are needed.

  5. Primary health care quality and hospitalizations for ambulatory care sensitive conditions in the public health system in Porto Alegre, Brazil.

    Science.gov (United States)

    Gonçalves, Marcelo Rodrigues; Hauser, Lisiane; Prestes, Isaías Valente; Schmidt, Maria Inês; Duncan, Bruce Bartholow; Harzheim, Erno

    2016-06-01

    To investigate the relation of hospitalization for ambulatory care sensitive conditions (ACSC) with the quality of public primary care health services in Porto Alegre, Brazil. Cohort study constructed by probabilistic record linkage performed from August 2006 to December 2011 in a population ≥18 years of age that attended public primary care health services. The Primary Care Assessment Tool (PCATool-Brazil) was used for evaluation of primary care services. Of 1200 subjects followed, 84 were hospitalized for primary care sensitive conditions. The main causes of ACSC hospital admissions were cardiovascular (40.5%) and respiratory (16.2%) diseases. The PCATool average score was 5.3, a level considerably below that considered to represent quality care. After adjustment through Cox proportional hazard modelling for covariates, >60 years of age [hazard ratio (HR): 1.13; P = 0.001), lesser education (HR: 0.66; P = 0.02), ethnicity other than white (HR: 1.77; P = 0.01) and physical inactivity (HR: 1.65; P = 0.04) predicted hospitalization, but higher quality of primary health care did not. Better quality of health care services, in a setting of overwhelmingly low quality services not adapted to the care of chronic conditions, did not influence the rate of avoidable hospitalizations, while social and demographic characteristics, especially non-white ethnicity and lesser schooling, indicate that social inequities play a predominant role in health outcomes. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  6. Age-Based Differences in Care Setting Transitions over the Last Year of Life

    Directory of Open Access Journals (Sweden)

    Donna M. Wilson

    2011-01-01

    Full Text Available Context. Little is known about the number and types of moves made in the last year of life to obtain healthcare and end-of-life support, with older adults more vulnerable to care setting transition issues. Research Objective. Compare care setting transitions across older (65+ years and younger individuals. Design. Secondary analyses of provincial hospital and ambulatory database data. Every individual who lived in the province for one year prior to death from April 1, 2005 through March 31, 2007 was retained (N=19,397. Results. Transitions averaged 3.5, with 3.9 and 3.4 for younger and older persons, respectively. Older persons also had fewer ER and ambulatory visits, fewer procedures performed in the last year of life, but longer inpatient stays (42.7 days versus 36.2 for younger persons. Conclusion. Younger and older persons differ somewhat in the number and type of end-of-life care setting transitions, a matter for continuing research and healthcare policy.

  7. Concerns of stem cell transplant patients during routine ambulatory assessment

    Directory of Open Access Journals (Sweden)

    Klein C

    2013-01-01

    Full Text Available Lisa Kennedy Sheldon,1 Maryum Kazmi,1 Cynthia Klein,2 Donna L Berry31University of Massachusetts Boston, Boston, MA, 2Seattle Cancer Care Alliance, Seattle, WA, 3Phyllis Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA, USABackground: Stem cell transplant (SCT is a treatment choice for many hematological malignancies. There is currently a lack of evidence regarding the self-reported concerns of SCT patients before and after SCT.Aim and design: This exploratory study performed a secondary analysis of self-reported, written concerns of SCT patients before and after transplant to determine patients' concerns.Methods: Content analysis of text box entries of SCT patients collected between 2005 and 2007 at the Seattle Cancer Care Alliance. Text box entries were collected as part of symptom assessment using the Electronic Self-Report Assessment – Cancer instrument. The assessment was presented to 137 patients undergoing SCT at two time points: prior to ambulatory visits before any therapy had begun (T1 and at the first visit after hospital discharge following SCT (T2.Results: Text box entries were made before (n = 52 and after (n = 87 the transplant, resulting in 139 text box entries made by 137 patients representing 133 concerns. Using content analysis, the entries were categorized and ranked according to frequency. After symptom concerns, patients ranked work and financial issues the most frequent concerns prior to SCT. After SCT, symptoms remained the most frequently entered area of concern, followed by survival.Conclusion: Oncology providers need to assess SCT patients for work and financial concerns before and after transplant. Appropriate and timely referrals may ease the burden of these concerns for patients. Thus, assessment of financial and work concerns by the oncology team should be an integral part of quality health care for patients undergoing SCT.Keywords: self-report, electronic

  8. Inconsistencies Exist in National Estimates of Eye Care Services Utilization in the United States

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    Fernando A. Wilson

    2015-01-01

    Full Text Available Background. There are limited research and substantial uncertainty about the level of eye care utilization in the United States. Objectives. Our study estimated eye care utilization using, to our knowledge, every known nationally representative, publicly available database with information on office-based optometry or ophthalmology services. Research Design. We analyzed the following national databases to estimate eye care utilization: the Medical Expenditure Panel Survey (MEPS, National Health Interview Survey (NHIS, Joint Canada/US Survey of Health (JCUSH, Behavioral Risk Factor Surveillance System (BRFSS, and the National Ambulatory Medical Care Survey (NAMCS. Subjects. US adults aged 18 and older. Measures. Self-reported utilization of eye care services. Results. The weighted number of adults seeing or talking with any eye doctor ranges from 87.9 million to 99.5 million, and the number of visits annually ranges from 72.9 million to 142.6 million. There were an estimated 17.2 million optometry visits and 55.8 million ophthalmology visits. Conclusions. The definitions and estimates of eye care services vary widely across national databases, leading to substantial differences in national estimates of eye care utilization.

  9. Parents' satisfaction with pediatric ambulatory anesthesia in northeast of Thailand.

    Science.gov (United States)

    Boonmak, Suhattaya; Boonmak, Polpun; Pothiruk, Kittawan; Hoontanee, Nattakhan

    2009-12-01

    Study the satisfaction of parents with ambulatory anesthesia and associated factors, including characteristics of the patients and their parents. This was a prospective, descriptive, observation study. The authors included children who were scheduled for ambulatory anesthetic service between birth and 14 years of age and attended at Srinagarind Hospital, Khon Kaen, Thailand. The authors excluded patients whose parents could not be reached by telephone. Before anesthesia, the authors recorded the patients and parents' characteristics, level of information perception (pre-, peri- and post-anesthesia and complications). After anesthesia, the anesthesia technique and any complications were recorded. The day after anesthesia, the authors made phone calls to the patients to record the parents' satisfaction score (viz, of overall, pre-, peri- and post-anesthesia care, and information about the level of patient care at home), and any anesthesia related complications. Ninety-two patients and their parents were included in the present study. Overall parents 'satisfaction with the anesthesia service was 96.7% (i.e., 89/92) (95% CI 90.8-99.3). Parents' satisfaction with pre- and peri-anesthesia care was 100% (95% CI 96.1-100) and 97.9% (95% CI 92.4-99.7), respectively. Parents' satisfaction with the PACU care and information of patient care at home was 96.7% (95% CI 90.8-99.3) and 91.3% (95% CI 83.6-96.2), respectively. Associated factors where parents were dissatisfied included PACU care satisfaction (i.e., relative risk 22.5 (95% CI 3.2-158)) and patient care information at home (i.e., relative risk 13.3 (95% CI 1.3-136.0)). The present study showed a high level of parents' satisfaction. Parents' dissatisfaction associated with PACU care and information about post anesthesia care at home. Additionally information on parents' characteristics provides invaluable data for improving pediatric ambulatory anesthesia in Srinagarind Hospital.

  10. Prediabetes Diagnosis and Treatment in Primary Care.

    Science.gov (United States)

    Mainous, Arch G; Tanner, Rebecca J; Baker, Richard

    2016-01-01

    The increasing prevalence of diabetes is a major health problem. The detection and treatment of prediabetes can delay the onset of diabetes and presents an important diabetes prevention strategy. Using data from the 2012 National Ambulatory Medical Care Survey, we studied visits by adults aged ≥45 years without diagnosed diabetes who had an HbA1c test within 90 days of the visit (n = 518 unweighted visits; n = 11,167,004 weighted visits). HbA1c results were categorized into normal, prediabetes, and diabetes, and we examined patient characteristics (age, sex, race, payer type, body mass index) and treatment of prediabetes. Among visiting adults, 54.6% had a normal HbA1c value, 33.6% had prediabetes, and 11.9% had diabetes. Of those patient visits with HbA1c consistent with prediabetes, the number of patients diagnosed with prediabetes was too low for a reliable population estimate. Indication of treatment in the medical record (lifestyle modification counseling and/or metformin) was present in 23.0% of those with diagnosed or undiagnosed prediabetes. The most common treatment was lifestyle modification counseling. Our findings show that there are missed opportunities for diabetes prevention in primary care. Providers need to change their approach to prediabetes and play a more effective role in preventing diabetes. © Copyright 2016 by the American Board of Family Medicine.

  11. Regional anesthesia techniques for ambulatory orthopedic surgery.

    LENUS (Irish Health Repository)

    O'Donnell, Brian D

    2012-02-03

    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.

  12. Preventing dehydration-related hospitalizations: a mixed-methods study of parents, inpatient attendings, and primary care physicians.

    Science.gov (United States)

    Shanley, Leticia; Mittal, Vineeta; Flores, Glenn

    2013-07-01

    The goal of this study was to identify the proportion of dehydration-related ambulatory care-sensitive condition hospitalizations, the reasons why these hospitalizations were preventable, and factors associated with preventability. A cross-sectional survey of primary care providers (PCPs), inpatient attending physicians, and parents was conducted in a consecutive series of children with ambulatory care-sensitive conditions admitted to an urban hospital over 14 months. Eighty-five children were diagnosed with dehydration. Their mean age was 1.6 years; most had public (74%) or no (17%) insurance, and were nonwhite (91%). The proportion of hospitalizations assessed as preventable varied from 12% for agreement among all 3 sources to 45% for any source. Parents identified inadequate prevention (50%), poor self-education (34%), and poor quality of care (38%) as key factors. PCPs identified parents providing insufficient home rehydration (33%), not visiting the clinic (25%), and not calling earlier (16%) as reasons. Inpatient attending physicians cited home rehydration (40%), delays in seeking care (40%), and lacking a PCP (20%) as contributors. Physicians (PCPs and inpatient attending physicians) were more likely than parents to describe the admission as inappropriate (75% vs 67% vs 0%; P dehydration-related hospitalizations may be preventable. Inadequate parental education by physicians, insufficient home rehydration, deferring clinic visits, insurance and cost barriers, inappropriate admissions, poor quality of care, and parental dissatisfaction with PCPs are the reasons that these hospitalizations might have been prevented.

  13. Pain Management in Ambulatory Surgery—A Review

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    Jan G. Jakobsson

    2014-07-01

    Full Text Available Day surgery, coming to and leaving the hospital on the same day as surgery as well as ambulatory surgery, leaving hospital within twenty-three hours is increasingly being adopted. There are several potential benefits associated with the avoidance of in-hospital care. Early discharge demands a rapid recovery and low incidence and intensity of surgery and anaesthesia related side-effects; such as pain, nausea and fatigue. Patients must be fit enough and symptom intensity so low that self-care is feasible in order to secure quality of care. Preventive multi-modal analgesia has become the gold standard. Administering paracetamol, NSIADs prior to start of surgery and decreasing the noxious influx by the use of local anaesthetics by peripheral block or infiltration in surgical field prior to incision and at wound closure in combination with intra-operative fast acting opioid analgesics, e.g., remifentanil, have become standard of care. Single preoperative 0.1 mg/kg dose dexamethasone has a combined action, anti-emetic and provides enhanced analgesia. Additional α-2-agonists and/or gabapentin or pregabalin may be used in addition to facilitate the pain management if patients are at risk for more pronounced pain. Paracetamol, NSAIDs and rescue oral opioid is the basic concept for self-care during the first 3–5 days after common day/ambulatory surgical procedures.

  14. Ambulatory Healthcare Utilization in the United States: A System Dynamics Approach

    Science.gov (United States)

    Diaz, Rafael; Behr, Joshua G.; Tulpule, Mandar

    2011-01-01

    Ambulatory health care needs within the United States are served by a wide range of hospitals, clinics, and private practices. The Emergency Department (ED) functions as an important point of supply for ambulatory healthcare services. Growth in our aging populations as well as changes stemming from broader healthcare reform are expected to continue trend in congestion and increasing demand for ED services. While congestion is, in part, a manifestation of unmatched demand, the state of the alignment between the demand for, and supply of, emergency department services affects quality of care and profitability. The central focus of this research is to provide an explanation of the salient factors at play within the dynamic demand-supply tensions within which ambulatory care is provided within an Emergency Department. A System Dynamics (SO) simulation model is used to capture the complexities among the intricate balance and conditional effects at play within the demand-supply emergency department environment. Conceptual clarification of the forces driving the elements within the system , quantifying these elements, and empirically capturing the interaction among these elements provides actionable knowledge for operational and strategic decision-making.

  15. Ambulatory orthopaedic surgery patients' knowledge with internet-based education.

    Science.gov (United States)

    Heikkinen, Katja; Leino-Kilpi, H; Salanterä, S

    2012-01-01

    There is a growing need for patient education and an evaluation of its outcomes. The aim of this study was to compare ambulatory orthopaedic surgery patients' knowledge with Internet-based education and face-to-face education with a nurse. The following hypothesis was proposed: Internet-based patient education (experiment) is as effective as face-to-face education with a nurse (control) in increasing patients' level of knowledge and sufficiency of knowledge. In addition, the correlations of demographic variables were tested. The patients were randomized to either an experiment group (n = 72) or a control group (n = 75). Empirical data were collected with two instruments. Patients in both groups showed improvement in their knowledge during their care. Patients in the experiment group improved their knowledge level significantly more in total than those patients in the control group. There were no differences in patients' sufficiency of knowledge between the groups. Knowledge was correlated especially with patients' age, gender and earlier ambulatory surgeries. As a conclusion, positive results concerning patients' knowledge could be achieved with the Internet-based education. The Internet is a viable method in ambulatory care.

  16. Ambulatory surgery for the patient with breast cancer: current perspectives

    Directory of Open Access Journals (Sweden)

    Pek CH

    2016-08-01

    Full Text Available Chong Han Pek,1 John Tey,2 Ern Yu Tan1 1Department of General Surgery, 2Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore, Singapore Abstract: Ambulatory breast cancer surgery is well accepted and is the standard of care at many tertiary centers. Rather than being hospitalized after surgery, patients are discharged on the day of surgery or within 23 hours. Such early discharge does not adversely affect patient outcomes and has the added benefits of better psychological adjustment for the patient, economic savings, and a more efficient utilization of health care resources. The minimal care needed post-discharge also means that the caregiver is not unduly burdened. Unplanned conversions to inpatient admission and readmission rates are low. Wound complications are infrequent and no issues with drain care have been reported. Because the period of postoperative observation is short and monitoring is not as intensive, ambulatory surgery is only suitable for low-risk procedures such as breast cancer surgery and in patients without serious comorbidities, where the likelihood of major perioperative events is low. Optimal management of pain, nausea, and vomiting is essential to ensure a quick recovery and return to normal function. Regional anesthesia such as the thoracic paravertebral block has been employed to improve pain control during the surgery and in the immediate postoperative period. The block provides excellent pain relief and reduces the need for opiates, which also consequently reduces the incidence of nausea and vomiting. The increasing popularity of total intravenous anesthesia with propofol has also helped reduce the incidence of nausea and vomiting in the postoperative period. Ambulatory surgery can be safely carried out in centers where there is a well-designed workflow to ensure proper patient selection, counseling, and education, and where patients and caregivers have easy access to

  17. Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis.

    Science.gov (United States)

    Whittaker, William; Anselmi, Laura; Kristensen, Søren Rud; Lau, Yiu-Shing; Bailey, Simon; Bower, Peter; Checkland, Katherine; Elvey, Rebecca; Rothwell, Katy; Stokes, Jonathan; Hodgson, Damian

    2016-09-01

    Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators. Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency

  18. Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis.

    Directory of Open Access Journals (Sweden)

    William Whittaker

    2016-09-01

    Full Text Available Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators.Throughout 2014, 56 primary care practices (346,024 patients in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866, and a 26.6% (95% CI -39.2% to -14.1% relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184. There was an insignificant relative reduction of 3.1% in

  19. Patient satisfaction and acceptability: a journey through an ambulatory gynaecology clinic in the West of Ireland

    LENUS (Irish Health Repository)

    Uzochukwu, I

    2016-06-01

    Ambulatory Gynaecology allows a “see-and-treat” approach to managing gynaecological conditions, providing a more streamlined, integrated care pathway than the traditional gynaecology clinic and inpatient care model. This study was designed to assess patient satisfaction and acceptability of Ambulatory Gynaecology services in Mayo University Hospital, Castlebar, Ireland. It also provided for feedback from patients as to how the service might be improved. \\r\

  20. Use of a voice and video internet technology as an alternative to in-person urgent care clinic visits.

    Science.gov (United States)

    Brunett, Patrick H; DiPiero, Albert; Flores, Christine; Choi, Dongseok; Kum, Hayley; Girard, Donald E

    2015-06-01

    This study aimed to determine the feasibility of patient-initiated online Internet urgent care visits, and to describe patient characteristics, scope of care, provider adherence to protocols, and diagnostic and therapeutic utilization. A total of 456 unique patients were seen via Internet-based technology during the study period, generating 478 consecutive total patient visits. Of the 82 patients referred for an in-person evaluation, 75 patients (91.5%) reported to the clinic as instructed. None of the 82 patients recommended for in-person evaluation required an emergency department referral, hospital admission or urgent consultative referral. We conclude that real-time online primary and urgent care visits are feasible, safe and potentially beneficial in increasing convenient access to urgent and primary care. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

  1. Mental health service use for adult patients with co-occurring depression and physical chronic health care needs, 2007-2010.

    Science.gov (United States)

    Jolles, Mónica Pérez; Haynes-Maslow, Lindsey; Roberts, Megan C; Dusetzina, Stacie B

    2015-08-01

    Individuals with mental illness experience poor health and may die prematurely from chronic illness. Understanding whether the presence of co-occurring chronic physical health conditions complicates mental health treatment is important, particularly among patients seeking treatment in primary care settings. Examine (1) whether the presence of chronic physical conditions is associated with mental health service use for individuals with depression who visit a primary care physician, and (2) whether race modifies this relationship. Secondary analysis of the National Ambulatory Medical Care Survey, a survey of patient-visits collected annually from a random sample of 3000 physicians in office-based settings. Office visits from 2007 to 2010 were pooled for adults aged 35-85 with a depression diagnosis at the time of visit (N=3659 visits). Mental health services were measured using a dichotomous variable indicating whether mental health services were provided during the office visit or a referral made for: (1) counseling, including psychotherapy and other mental health counseling and/or (2) prescribing of psychotropic medications. Most patient office visits (70%) where a depression diagnosis was recorded also had co-occurring chronic physical conditions recorded. The presence of at least 1 physical chronic condition was associated with a 6% decrease in the probability of receiving any mental health services (Phealth conditions, particularly as the health care system moves toward an integrated care model.

  2. Women's education level, antenatal visits and the quality of skilled antenatal care: a study of three African countries.

    Science.gov (United States)

    Babalola, Stella

    2014-02-01

    Many pregnant women in Africa who access professional antenatal care do not receive all the WHO-recommended components of care. Using Demographic and Health Survey (DHS) data from Kenya, Malawi and Nigeria, this study assesses the relationship of education level with the quality of antenatal care received and highlights how the number of antenatal visits mediates this relationship. The results show that a large proportion of the effect of education level on quality of care is direct, while only a small portion is mediated through the number of antenatal visits. Efforts to improve pregnancy outcomes for under-privileged women should focus on removing structural barriers to access, strengthening the technical and interpersonal skills of providers, and addressing providers' biases and discriminatory practices towards these women. Such efforts should also seek to empower underprivileged women to insist on quality antenatal care by explaining what to expect during an antenatal visit.

  3. Functional, interactive and critical health literacy: Varying relationships with control over care and number of GP visits.

    Science.gov (United States)

    van der Heide, Iris; Heijmans, Monique; Schuit, A Jantine; Uiters, Ellen; Rademakers, Jany

    2015-08-01

    The aim of this study is to examine the extent to which functional, interactive and critical health literacy are associated with patients' perceived control over care and frequency of GP visits. Data from the Dutch 'National Panel of People with Chronic Illness or Disability' was used (N=2508). Health literacy was assessed by the Functional, Communicative and Critical Health Literacy measure. Perceived control over care was indicated by perceived ability to organize care, interact with providers and to perform self-care. By multivariate linear and logistic regression analyses, associations between health literacy and perceived control over care and subsequently frequency of GP visits were studied. Mainly interactive health literacy was associated with patients' perceived ability to organize care, interact with healthcare providers and perform self-care, whereas only functional health literacy was associated with number of GP visits. The results imply that some patients' may be less able to exert control over their care because of lower health literacy. Functional, interactive and critical health literacy vary in their relevance for patients' ability to exert control. Initiatives for strengthening patients' role in healthcare may be improved by paying attention to patients' health literacy, specifically functional and interactive health literacy. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  4. A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents.

    Science.gov (United States)

    Szilagyi, Peter G; Albertin, Christina; Humiston, Sharon G; Rand, Cynthia M; Schaffer, Stanley; Brill, Howard; Stankaitis, Joseph; Yoo, Byung-Kwang; Blumkin, Aaron; Stokley, Shannon

    2013-01-01

    To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents. We conducted a randomized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11-17 years to one of three groups: mailed letter, telephone reminders, or control. Publicly insured youths (n = 4115) were identified in 37 participating primary care practices. The main outcome measures were immunization rates for routine vaccines (meningococcus, pertussis, HPV) and preventive visit rates at study end. Intervention and control groups were similar at baseline for demographics, immunization rates, and preventive visits. Among adolescents who were behind at the start, immunization rates at study end increased by 21% for mailed (P immunizations and preventive visits, with modest costs and modest impact. Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

  5. The proportion of work-related emergency department visits not expected to be paid by workers' compensation: implications for occupational health surveillance, research, policy, and health equity.

    Science.gov (United States)

    Groenewold, Matthew R; Baron, Sherry L

    2013-12-01

    To examine trends in the proportion of work-related emergency department visits not expected to be paid by workers' compensation during 2003-2006, and to identify demographic and clinical correlates of such visits. A total of 3,881 work-related emergency department visit records drawn from the 2003-2006 National Hospital Ambulatory Medical Care Surveys. Secondary, cross-sectional analyses of work-related emergency department visit data were performed. Odds ratios and 95 percent confidence intervals were modeled using logistic regression. A substantial and increasing proportion of work-related emergency department visits in the United States were not expected to be paid by workers' compensation. Private insurance, Medicaid, Medicare, and workers themselves were expected to pay for 40 percent of the work-related emergency department visits with this percentage increasing annually. Work-related visits by blacks, in the South, to for-profit hospitals and for work-related illnesses were all more likely not to be paid by workers' compensation. Emergency department-based surveillance and research that determine work-relatedness on the basis of expected payment by workers' compensation systematically underestimate the occurrence of occupational illness and injury. This has important methodological and policy implications. © Health Research and Educational Trust.

  6. After-visit summaries in primary care: mixed methods results from a literature review and stakeholder interviews.

    Science.gov (United States)

    Lyles, Courtney R; Gupta, Reena; Tieu, Lina; Fernandez, Alicia

    2018-05-28

    After-visit summary (AVS) documents presenting key information from each medical encounter have become standard in the USA due to federal health care reform. Little is known about how they are used or whether they improve patient care. First, we completed a literature review and described the totality of the literature on AVS by article type and major outcome measures. Next, we used reputational sampling from large-scale US studies on primary care to identify and interview nine stakeholders on their perceptions of AVS across high-performing primary care practices. Interviews were transcribed and coded for AVS use in practice, perceptions of the best/worst features and recommendations for improving AVS utility in routine care. The literature review resulted in 17 studies; patients reported higher perceived value of AVS compared with providers, despite poor recall of specific AVS content and varied post-visit use. In key informant interviews, key informants expressed enthusiasm for the potential of using AVS to reinforce key information with patients, especially if AVS were customizable. Despite this potential, key informants found that AVS included incorrect information and did not feel that patients or their practices were using AVS to enhance care. There is a gap between the potential of AVS and how providers and patients are using it in routine care. Suggestions for improved use of AVS include increasing customization, establishing care team responsibilities and workflows and ensuring patients with communication barriers have dedicated support to review AVS during visits.

  7. Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting

    Directory of Open Access Journals (Sweden)

    Vadivelu N

    2016-06-01

    Full Text Available Nalini Vadivelu,1 Alice M Kai,2 Vijay Kodumudi,3 Jack M Berger4 1Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, 2Stony Brook University School of Medicine, Stony Brook, NY, 3Department of Molecular and Cell Biology, College of Liberal Arts and Sciences, University of Connecticut, Storrs, CT, 4Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA Abstract: 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

  8. Characteristics of physicians and patients who join team-based primary care practices: evidence from Quebec's Family Medicine Groups.

    Science.gov (United States)

    Coyle, Natalie; Strumpf, Erin; Fiset-Laniel, Julie; Tousignant, Pierre; Roy, Yves

    2014-06-01

    New models of delivering primary care are being implemented in various countries. In Quebec, Family Medicine Groups (FMGs) are a team-based approach to enhance access to, and coordination of, care. We examined whether physicians' and patients' characteristics predicted their participation in this new model of primary care. Using provincial administrative data, we created a population cohort of Quebec's vulnerable patients. We collected data before the advent of FMGs on patients' demographic characteristics, chronic illnesses and health service use, and their physicians' demographics, and practice characteristics. Multivariate regression was used to identify key predictors of joining a FMG among both patients and physicians. Patients who eventually enrolled in a FMG were more likely to be female, reside outside of an urban region, have a lower SES status, have diabetes and congestive heart failure, visit the emergency department for ambulatory sensitive conditions and be hospitalized for any cause. They were also less likely to have hypertension, visit an ambulatory clinic and have a usual provider of care. Physicians who joined a FMG were less likely to be located in urban locations, had fewer years in medical practice, saw more patients in hospital, and had patients with lower morbidity. Physicians' practice characteristics and patients' health status and health care service use were important predictors of joining a FMG. To avoid basing policy decisions on tenuous evidence, policymakers and researchers should account for differential selection into team-based primary health care models. Copyright © 2014. Published by Elsevier Ireland Ltd.

  9. Diagnostic value and cost-benefit analysis of 24?hours ambulatory blood pressure monitoring in primary care in Portugal

    OpenAIRE

    Pessanha, Paulo; Viana, Manuel; Ferreira, Paula; Bertoquini, Susana; Pol?nia, Jorge

    2013-01-01

    Background Hypertensive patients (HTs) are usually attended in primary care (PC). We aimed to assess the diagnostic accuracy and cost-benefit ratio of 24-hour ambulatory blood pressure monitoring (ABPM) in all newly diagnosed hypertensive patients (HTs) attended in PC. Methods In a cross-sectional study ABPM was recorded in all 336 never treated HTs (Office BP ?140 and/or???90?mm Hg) that were admitted during 16?months. Since benefits from drug treatment in white-coat hypertension (WCH) remai...

  10. Nonemergency medical transportation and health care visits among chronically ill urban and rural medicaid beneficiaries.

    Science.gov (United States)

    Thomas, Leela V; Wedel, Kenneth R

    2014-01-01

    Inaccessibility to health care services due to lack of transportation affects the most vulnerable segments of the society. The effect of Medicaid-provided nonemergency medical transportation (NEMT) in Oklahoma on health care visits for the management of chronic illnesses is examined. Analyses of claims data show that African Americans are the highest users of NEMT. Medicaid beneficiaries who use NEMT services are significantly more likely to make the recommended number of annual visits for the management of chronic conditions than those who do not use NEMT. Increased use of NEMT by making the services more accommodating and convenient for beneficiaries is proposed.

  11. Hospitalizations for ambulatory care sensitive conditions and quality of primary care: their relation with socioeconomic and health care variables in the Madrid regional health service (Spain).

    Science.gov (United States)

    Magán, Purificación; Alberquilla, Angel; Otero, Angel; Ribera, José Manuel

    2011-01-01

    Hospitalizations for ambulatory care sensitive conditions (ACSH) have been proposed as an indirect indicator of the effectiveness and quality of care provided by primary health care. To investigate the association of ACSH rates with population socioeconomic factors and with characteristics of primary health care. Cross-sectional, ecologic study. Using hospital discharge data, ACSH were selected from the list of conditions validated for Spain. All 34 health districts in the Region of Madrid, Spain. Individuals aged 65 years or older residing in the region of Madrid between 2001 and 2003, inclusive. Age- and gender-adjusted ACSH rates in each health district. The adjusted ACSH rate per 1000 population was 35.37 in men and 20.45 in women. In the Poisson regression analysis, an inverse relation was seen between ACSH rates and the socioeconomic variables. Physician workload was the only health care variable with a statistically significant relation (rate ratio of 1.066 [95% CI; 1.041-1.091]). These results were similar in the analyses disaggregated by gender. In the multivariate analyses that included health care variables, none of the health care variables were statistically significant. ACSH may be more closely related with socioeconomic variables than with characteristics of primary care activity. Therefore, other factors outside the health system must be considered to improve health outcomes in the population.

  12. One-Year Effect of the Medicare Annual Wellness Visit on Detection of Cognitive Impairment: A Cohort Study.

    Science.gov (United States)

    Fowler, Nicole R; Campbell, Noll L; Pohl, Gerhardt M; Munsie, Leanne M; Kirson, Noam Y; Desai, Urvi; Trieschman, Erich J; Meiselbach, Mark K; Andrews, J Scott; Boustani, Malaz A

    2018-04-02

    To examine the effect of the Medicare Annual Wellness Visit (AWV) on the detection of cognitive impairment and on follow-up cognitive care for older adults. Retrospective matched-cohort study. United States. A 5% random sample of fee-for-service Medicare beneficiaries continuously enrolled for 12 months before and after an index ambulatory visit occurring from 2011 to 2013 with no claims evidence of cognitive impairment before index. Outcomes include 12-month post-index visit claims-based measurements of cognitive impairment, including new Alzheimer's disease and related dementia (ADRD) diagnoses; medications for ADRD; and cognitive care-related diagnostic examination such as neurobehavioral testing, brain imaging, and blood tests for thyroid-stimulating hormone (TSH), serum B12, folate, and syphilis. We also measured changes in burden of anticholinergic medication. There were no clinically relevant differences between the AWV and control groups in the rates of incident ADRD diagnoses (6.16% vs 6.86%, p<.001) and initiation of ADRD medications (1.00% vs 1.08%, p=.15), although there were differences favoring the AWV group in rates of TSH (39.80% vs 28.36%, p<.001), B12 (9.41% vs 6.97%, p<.001), folate (4.76% vs 3.72%, p<.001), and neurobehavioral (0.75% vs 0.55%, p<.001) testing. Although the AWV is correlated with an increase in some measures of cognitive care, such as laboratory testing for reversible causes of cognitive impairment, it does not appear to substantially increase recognition of undetected ADRD. © 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.

  13. Nurse-measured or ambulatory blood pressure in routine hypertension care

    NARCIS (Netherlands)

    Veerman, D. P.; van Montfrans, G. A.

    1993-01-01

    Nurses are considered to evoke less white-coat hypertension, and might therefore be able to estimate average blood pressure as well as and more conveniently than ambulatory monitoring. The objective of the present study was to determine the correspondence between blood pressure measured by a doctor

  14. [Considerations on local-regional anesthesia for ambulatory tooth extractions in patients with heart disease].

    Science.gov (United States)

    Debernardi, G; Borgogna, E

    1975-01-01

    Ambulatory dental extraction was performed on 150 patients with various forms of heart disease. No serious complications were noted with an anaesthetic without vasoconstriction (plain 3% carbocaine). The prior history was carefully studied and pressure values were determined. It is felt that heart disease does not form an absolute contraindication to ambulatory dental extraction.

  15. Estimated time spent on preventive services by primary care physicians

    Directory of Open Access Journals (Sweden)

    Gradison Margaret

    2008-12-01

    Full Text Available Abstract Background Delivery of preventive health services in primary care is lacking. One of the main barriers is lack of time. We estimated the amount of time primary care physicians spend on important preventive health services. Methods We analyzed a large dataset of primary care (family and internal medicine visits using the National Ambulatory Medical Care Survey (2001–4; analyses were conducted 2007–8. Multiple linear regression was used to estimate the amount of time spent delivering each preventive service, controlling for demographic covariates. Results Preventive visits were longer than chronic care visits (M = 22.4, SD = 11.8, M = 18.9, SD = 9.2, respectively. New patients required more time from physicians. Services on which physicians spent relatively more time were prostate specific antigen (PSA, cholesterol, Papanicolaou (Pap smear, mammography, exercise counseling, and blood pressure. Physicians spent less time than recommended on two "A" rated ("good evidence" services, tobacco cessation and Pap smear (in preventive visits, and one "B" rated ("at least fair evidence" service, nutrition counseling. Physicians spent substantial time on two services that have an "I" rating ("inconclusive evidence of effectiveness", PSA and exercise counseling. Conclusion Even with limited time, physicians address many of the "A" rated services adequately. However, they may be spending less time than recommended for important services, especially smoking cessation, Pap smear, and nutrition counseling. Future research is needed to understand how physicians decide how to allocate their time to address preventive health.

  16. Cost and Predictors of Hospitalizations for Ambulatory Care - Sensitive Conditions Among Medicaid Enrollees in Comprehensive Managed Care Plans

    Directory of Open Access Journals (Sweden)

    William N. Mkanta

    2016-09-01

    Full Text Available Introduction: Preventable hospitalizations are responsible for increasing the cost of health care and reflect ineffectiveness of the health services in the primary care setting. The objective of this study was to assess expenditure for hospitalizations and utilize expenditure differentials to determine factors associated with ambulatory care - sensitive conditions (ACSCs hospitalizations. Methods: A cross-sectional study of hospitalizations among Medicaid enrollees in comprehensive managed care plans in 2009 was conducted. A total of 25 581 patients were included in the analysis. Expenditures on hospitalizations were examined at the 50th, 75th, 90th, and 95th expenditure percentiles both at the bivariate level and in the logistic regression model to determine the impact of differing expenditure on ACSC hospitalizations. Results: Compared with patients without ACSC admissions, a larger proportion of patients with ACSC hospitalizations required advanced treatment or died on admission. Overall mean expenditures were higher for the ACSC group than for non-ACSC group (US$18 070 vs US$14 452. Whites and blacks had higher expenditures for ACSC hospitalization than Hispanics at all expenditure percentiles. Patient’s age remained a consistent predictor of ACSC hospitalization across all expenditure percentiles. Patients with ACSC were less likely to have a procedure on admission; however, the likelihood decreased as expenditure percentiles increased. At the median expenditure, blacks and Hispanics were more likely than other race/ethnic groups to have ACSC hospitalizations (odds ratio [OR]: 1.307, 95% confidence interval [CI]: 1.013-1.686 and OR 1.252, 95% CI: 1.060-1.479, respectively. Conclusion: Future review of delivery and monitoring of services at the primary care setting should include managed care plans in order to enhance access and overall quality of care for optimal utilization of the resources.

  17. Changes in insurance status and emergency department visits after the 2008 economic downturn.

    Science.gov (United States)

    Watts, Susan H; David Bryan, E; Tarwater, Patrick M

    2015-01-01

    As the U.S. economy began its downward trend in 2008, many citizens lost their jobs and, ultimately, their employer-sponsored health care insurance. The expectation was that many of the newly uninsured would turn to emergency departments (EDs) for their health care. This study was undertaken to determine, first, if changes in the insurance status of the general population were reflected in the ED insurance payer mix and, second, whether there was evidence of an increased reliance on the ED as a continuing source of health care for any payer group(s). This was a retrospective observational study using public data files from the National Hospital Ambulatory Medical Care Survey for Emergency Departments for years 2006 through 2010 (2008 ± 2 years). Changes in the relative proportions of ED visits funded annually by private insurance, Medicaid, Medicare, and self-pay (uninsured) were analyzed using a logistic model. Poisson regression was used to compare trends in the rates of ED visits for each payer type (i.e., number of ED visits per 100 persons with each insurance type). A linear spline term was used to determine if there was a change in each risk estimate after 2008 compared to the risk estimate before 2008. Before 2008, the odds of an ED visit being funded by private insurance increased by 4% per year (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 0.98 to 1.10; p = 0.15), but after 2008 the odds reversed, decreasing by nearly 10% per year (OR = 0.91, 95% CI = 0.85 to 0.97; p = 0.02). Medicaid-funded visits demonstrated opposite trends with a small decreasing trend of 2% per year before 2008 (OR = 0.98, 95% CI = 0.92 to 1.04; p = 0.52), followed by a significantly increasing trend of 20% per year after 2008 (OR = 1.20, 95% CI = 1.12 to 1.27; p = 0.001). The growth in Medicaid-funded ED visits was attributable to increased numbers of visits by both pediatric (<18 years old) and non-elderly adult (19 to 64 years old) patients. For both Medicaid and private

  18. Neighborhood Child Opportunity and Individual-Level Pediatric Acute Care Use and Diagnoses.

    Science.gov (United States)

    Kersten, Ellen E; Adler, Nancy E; Gottlieb, Laura; Jutte, Douglas P; Robinson, Sarah; Roundfield, Katrina; LeWinn, Kaja Z

    2018-05-01

    : media-1vid110.1542/5751513300001PEDS-VA_2017-2309 Video Abstract OBJECTIVES: Although health care providers and systems are increasingly interested in patients' nonmedical needs as a means to improve health, little is known about neighborhood conditions that contribute to child health problems. We sought to determine if a novel, publicly available measure of neighborhood context, the Child Opportunity Index, was associated with pediatric acute care visit frequency and diagnoses. This cross-sectional study included San Francisco residents <18 years of age with an emergency department and/or urgent care visit to any of 3 medical systems ( N = 47 175) between 2007 and 2011. Hot-spot analysis was used to compare the spatial distribution of neighborhood child opportunity and income. Generalized estimating equation logistic regression models were used to examine independent associations between neighborhood child opportunity and frequent acute care use (≥4 visits per year) and diagnosis group after adjusting for neighborhood income and patient age, sex, race and/or ethnicity, payer, and health system. Neighborhood child opportunity and income had distinct spatial distributions, and we identified different clusters of high- and low-risk neighborhoods. Children living in the lowest opportunity neighborhoods had significantly greater odds of ≥4 acute care visits per year (odds ratio 1.33; 95% confidence interval 1.03-1.73) compared with those in the highest opportunity neighborhoods. Neighborhood child opportunity was negatively associated with visits for respiratory conditions, asthma, assault, and ambulatory care-sensitive conditions but positively associated with injury-related visits. The Child Opportunity Index could be an effective tool for identifying neighborhood factors beyond income related to child health. Copyright © 2018 by the American Academy of Pediatrics.

  19. Working in clients' homes: the impact on the mental health and well-being of visiting home care workers.

    Science.gov (United States)

    Denton, Margaret A; Zeytinoğlu, Işk Urla; Davies, Sharon

    2002-01-01

    The purpose of this paper is to examine the effects of working in clients' homes on the mental health and well-being of visiting home care workers. This paper reports the results of a survey of 674 visiting staff from three non-profit home care agencies in a medium-sized city in Ontario, Canada. Survey results are also complimented by data from 9 focus groups with 50 employees. For purposes of this study, home care workers include visiting therapists, nurses, and home support workers. Mental health and well-being is measured by three dependent variables: stress; job stress; and intrinsic job satisfaction. Multiple least squared regression analyses show several structural, emotional, physical, and organizational working conditions associated with the health and well-being of visiting home care workers. Overall, results show that workload, difficult clients, clients who take advantage of workers, sexual harassment, safety hazards, a repetitious job, and work-related injuries are associated with poorer health. Being fairly paid, having good benefits, emotional labour, organizational support, control over work, and peer support are associated with better health. Results suggest that policy change is needed to encourage healthier work environments for employees who work in clients' homes.

  20. Management of abnormal uterine bleeding – focus on ambulatory hysteroscopy

    Directory of Open Access Journals (Sweden)

    Kolhe S

    2018-03-01

    Full Text Available Shilpa Kolhe Ambulatory Gynaecology Unit, Royal Derby Hospital, Derby, UK Abstract: The rapid evolution in ambulatory hysteroscopy (AH has transformed the approach to diagnose and manage abnormal uterine bleeding (AUB. The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting. Keywords: abnormal uterine bleeding, ambulatory hysteroscopy, endometrial polyps, one-stop clinic, vaginoscopic approach

  1. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus.

    Science.gov (United States)

    Pallin, Daniel J; Egan, Daniel J; Pelletier, Andrea J; Espinola, Janice A; Hooper, David C; Camargo, Carlos A

    2008-03-01

    Test the hypotheses that emergency department (ED) visits for skin and soft tissue infections became more frequent during the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA), and that antibiotics typically active against community-associated MRSA were chosen increasingly. From merged National Hospital Ambulatory Medical Care Survey data for 1993-2005, we identified ED visits with diagnosis of cellulitis, abscess, felon, impetigo, hidradenitis, folliculitis, infective mastitis, nonpurulent mastitis, breast abscess, or carbuncle and furuncle. Main outcomes were change over time in rate of ED visits with such a diagnosis and proportion of antibiotic regimens including an agent typically active against community-associated MRSA. We report national estimates derived from sample weights. We tested trends with least squares linear regression. In 1993, infections of interest were diagnosed at 1.2 million visits (95% confidence interval [CI] 0.96 to 1.5 million) versus 3.4 million in 2005 (95% CI 2.8 to 4.1 million; P for trend trend trend skin and soft tissue infections increased markedly from 1993 to 2005, contemporaneously with the emergence of community-associated MRSA. ED clinicians prescribed more antibiotics typically active against community-associated MRSA, especially trimethoprim-sulfamethoxazole. Possible confounders are discussed, such as increasing diabetes or shifts in locus of care.

  2. Ambulatory surgery centers best practices for the 90s.

    Science.gov (United States)

    Hoover, J A

    1994-05-01

    Outpatient surgery will be the driving force in the continued growth of ambulatory care in the 1990s. Providing efficient, high-quality ambulatory surgical services should therefore be a priority among healthcare providers. Arthur Andersen conducted a survey to discover best practices in ambulatory surgical service. General success characteristics of best performers were business-focused relationships with physicians, the use of clinical protocols, patient convenience, cost management, strong leadership, teamwork, streamlined processes and efficient design. Other important factors included scheduling to maximize OR room use; achieving surgical efficiencies through reduced case pack assembly errors and equipment availability; a focus on cost capture rather than charge capture; sound materiel management practices, such as standardization and vendor teaming; and the appropriate use of automated systems. It is important to evaluate whether the best practices are applicable to your environment and what specific changes to your current processes would be necessary to adopt them.

  3. Utilization of head CT during injury visits to United States emergency departments: 2012-2015.

    Science.gov (United States)

    Yun, Brian J; Borczuk, Pierre; Zachrison, Kori S; Goldstein, Joshua N; Berlyand, Yosef; Raja, Ali S

    2018-05-18

    Studies have shown increasing utilization of head computed tomography (CT) imaging of emergency department (ED) patients presenting with an injury-related visit. Multiple initiatives, including the Choosing Wisely™ campaign and evidence-based clinical decision support based on validated decision rules, have targeted head CT use in patients with injuries. Therefore, we investigated national trends in the use of head CT during injury-related ED visits from 2012 to 2015. This was a secondary analysis of data from the annual United States (U.S.) National Hospital Ambulatory Medical Care Survey from 2012 to 2015. The study population was defined as injury-related ED visits, and we sought to determine the percentage in which a head CT was ordered and, secondarily, to determine both the diagnostic yield of clinically significant intracranial findings and hospital characteristics associated with increased head CT utilization. Between 2012 and 2015, 12.25% (95% confidence interval [CI] 11.48-13.02%) of injury-related visits received at least one head CT. Overall head CT utilization showed an increased trend during the study period (2012: 11.7%, 2015: 13.23%, p = 0.09), but the results were not statistically significant. The diagnostic yield of head CT for a significant intracranial injury over the period of four years was 7.4% (9.68% in 2012 vs. 7.67% in 2015, p = 0.23). Head CT use along with diagnostic yield has remained stable from 2012 to 2015 among patients presenting to the ED for an injury-related visit. Copyright © 2017 Elsevier Inc. All rights reserved.

  4. Ambulatory oral surgery: 1-year experience with 11680 patients from Zagreb district, Croatia.

    Science.gov (United States)

    Jokić, Dražen; Macan, Darko; Perić, Berislav; Tadić, Marinka; Biočić, Josip; Đanić, Petar; Brajdić, Davor

    2013-02-01

    To examine the types and frequencies of oral surgery diagnoses and ambulatory oral surgical treatments during one year period at the Department of Oral Surgery, University Hospital Dubrava in Zagreb, Croatia. Sociodemographic and clinical data on 11680 ambulatory patients, treated between January 1 and of December 31, 2011 were retrieved from the hospital database using a specific protocol. The obtained data were subsequently analyzed in order to assess the frequency of diagnoses and differences in sex and age. The most common ambulatory procedure was tooth extraction (37.67%) and the most common procedure in ambulatory operating room was alveolectomy (57.25%). The test of proportions showed that significantly more extractions (PZagreb than in patients residing in rural areas. The data from this study may be useful for planning of ambulatory oral surgery services, budgeting, and sustaining quality improvement, enhancing oral surgical curricula, training and education of primary health care doctors and oral surgery specialists, and promoting patients' awareness of the importance of oral health.

  5. Developing a business-practice model for pharmacy services in ambulatory settings.

    Science.gov (United States)

    Harris, Ila M; Baker, Ed; Berry, Tricia M; Halloran, Mary Ann; Lindauer, Kathleen; Ragucci, Kelly R; McGivney, Melissa Somma; Taylor, A Thomas; Haines, Stuart T

    2008-02-01

    A business-practice model is a guide, or toolkit, to assist managers and clinical pharmacy practitioners in the exploration, proposal, development and implementation of new clinical pharmacy services and/or the enhancement of existing services. This document was developed by the American College of Clinical Pharmacy Task Force on Ambulatory Practice to assist clinical pharmacy practitioners and administrators in the development of business-practice models for new and existing clinical pharmacy services in ambulatory settings. This document provides detailed instructions, examples, and resources on conducting a market assessment and a needs assessment, types of clinical services, operations, legal and regulatory issues, marketing and promotion, service development and exit plan, evaluation of service outcomes, and financial considerations in the development of a clinical pharmacy service in the ambulatory environment. Available literature is summarized, and an appendix provides valuable citations and resources. As ambulatory care practices continue to evolve, there will be increased knowledge of how to initiate and expand the services. This document is intended to serve as an essential resource to assist in the growth and development of clinical pharmacy services in the ambulatory environment.

  6. The Impact of Telehealth and Care Coordination on the Number and Type of Clinical Visits for Children With Medical Complexity.

    Science.gov (United States)

    McKissick, Holly D; Cady, Rhonda G; Looman, Wendy S; Finkelstein, Stanley M

    The purpose of this analysis was to evaluate the effects of an advanced practice nurse-delivered telehealth intervention on health care use by children with medical complexity (CMC). Because CMC account for a large share of health care use costs, finding effective ways to care for them is an important challenge requiring exploration. This was a secondary analysis of data from a randomized clinical trial with a control group and two intervention groups. The focus of the analysis was planned and unplanned clinical and therapy visits by CMC over a 30-month data collection period. Nonparametric tests were used to compare visit counts among and within the three groups. The number of unplanned visits decreased over time across all groups, with the greatest decrease in the video telehealth intervention group. Planned visits were higher in the video telehealth group across all time periods. Advanced practice registered nurse-delivered telehealth care coordination may support a shift from unplanned to planned health care service use among CMC. Copyright © 2016 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.

  7. The Medicare Annual Wellness Visit.

    Science.gov (United States)

    Colburn, Jessica L; Nothelle, Stephanie

    2018-02-01

    The Medicare Annual Wellness Visit is an annual preventive health benefit, which was created in 2011 as part of the Patient Protection and Affordable Care Act. The visit provides an opportunity for clinicians to review preventive health recommendations and screen for geriatric syndromes. In this article, the authors review the requirements of the Annual Wellness Visit, discuss ways to use the Annual Wellness Visit to improve the care of geriatric patients, and provide suggestions for how to incorporate this benefit into a busy clinic. Copyright © 2017 Elsevier Inc. All rights reserved.

  8. Attribute correlates of hospital outpatient satisfaction.

    Science.gov (United States)

    Krueckeberg, H F; Hubbert, A

    1995-01-01

    Customer satisfaction (patient satisfaction) with hospital outpatient or ambulatory services is an important factor in influencing patient patronage and loyalty. Based on an empirical study, this article examines the attributes of the ambulatory care experience which were significantly associated with the level of satisfaction resulting from the most recent hospital ambulatory visit. This study focuses on identifying attributes of ambulatory services. This article brings to the health care marketing literature information on ambulatory satisfaction comparable to that which has been contributed to the literature regarding satisfaction with physician and hospital experiences.

  9. Multidisciplinary team approach to improved chronic care management for diabetic patients in an urban safety net ambulatory care clinic.

    Science.gov (United States)

    Tapp, Hazel; Phillips, Shay E; Waxman, Dael; Alexander, Matthew; Brown, Rhett; Hall, Mary

    2012-01-01

    Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.

  10. Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate.

    Science.gov (United States)

    Chung, Sukyung; Lesser, Lenard I; Lauderdale, Diane S; Johns, Nicole E; Palaniappan, Latha P; Luft, Harold S

    2015-01-01

    Under the Affordable Care Act (ACA), Medicare coverage expanded in 2011 to fully cover annual preventive care visits. We assessed the impact of coverage expansion, using 2007-13 data from primary care patients of Medicare-eligible age at the Palo Alto Medical Foundation (204,388 patient-years), which serves people in four counties near San Francisco, California. We compared trends in preventive visits and recommended preventive services among Medicare fee-for-service and Medicare health maintenance organization (HMO) patients as well as non-Medicare patients ages 65-75 who were covered by private fee-for-service and private HMO plans. Among Medicare fee-for-service patients, the annual use of preventive visits rose from 1.4 percent before the implementation of the ACA to 27.5 percent afterward. This increase was significantly larger than was seen for patients in the other insurance groups. Nevertheless, rates of annual preventive care visit use among Medicare fee-for-service patients remained 10-20 percentage points lower than was the case for people with private coverage (43-44 percent) or those in a Medicare HMO (53 percent). ACA policy changes led to increased preventive service use by Medicare fee-for-service beneficiaries, which suggests that Medicare coverage expansion is an effective way to increase seniors' use of preventive services. Project HOPE—The People-to-People Health Foundation, Inc.

  11. Socio Demographic Factors Determining the Adequacy of Antenatal Care among Pregnant Women Visiting Ekiti State Primary Health Centers

    Directory of Open Access Journals (Sweden)

    Ikeoluwapo O. Ajayi

    2013-08-01

    Full Text Available A cross sectional study was conducted in Primary Health Centers among pregnant women to elucidate adequacy of antenatal care across different socio demographic variables. Four hundred respondents were proportionately selected from 18 primary health centers using simple random sampling. Exit interviews were conducted using the adapted antenatal care exit interview form of the Safe Motherhood Needs Assessment package. Data was analyzed using descriptive statistics and Chi square test. Adequacy of antenatal care in this study was measured by the single adequacy indicators which are duration of pregnancy at entry into antenatal care and number of antenatal visits; which are particularly suitable for developing countries. Age of respondents, means of transportation to the PHCs, occupation, location and level of education of the respondents were found to be determinants of whether the pregnant women attended their first antenatal visit in the first trimester, similarly, age of the respondents was a predictor of whether the women made up to four antenatal visits by their third trimester. Occupation and level of education were determinants of whether or not the pregnant women made their first antenatal visits at the first trimester. More respondents who were not working and those who were unskilled workers made their first antenatal visit at the first trimester compared to those who were skilled workers; work place policies and the fact that antenatal booking are made on weekdays and at work hours may hinder or be discouraging to the working class mothers.

  12. Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review.

    Science.gov (United States)

    Keller, Sara C; Tamma, Pranita D; Cosgrove, Sara E; Miller, Melissa A; Sateia, Heather; Szymczak, Julie; Gurses, Ayse P; Linder, Jeffrey A

    2018-01-01

    In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation. We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment. Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS. A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS. © Copyright 2018 by the American Board of Family Medicine.

  13. Acupuncture in ambulatory anesthesia: a review

    Directory of Open Access Journals (Sweden)

    Norheim AJ

    2015-09-01

    Full Text Available Arne Johan Norheim,1 Ingrid Liodden,1 Terje Alræk1,2 1National Research Center in Complementary and Alternative Medicine (NAFKAM, Department of Community Medicine, Faculty of Health Sciences, University of Tromsø – The Arctic University of Norway, Tromsø, 2The Norwegian School of Health Sciences, Institute of Acupuncture, Kristiania University College, Oslo, NorwayBackground: Post-anesthetic morbidities remain challenging in our daily practice of anesthesia. Meta-analyses and reviews of acupuncture and related techniques for postoperative nausea and vomiting (POVN and postoperative vomiting (POV show promising results while many clinicians remain skeptical of the value of acupuncture. Given the interest in finding safe non-pharmacological approaches toward postoperative care, this body of knowledge needs to be considered. This review critically appraises and summarizes the research on acupuncture and acupressure in ambulatory anesthesia during the last 15 years.Methods: Articles were identified through searches of Medline, PubMed, and Embase using the search terms “acupuncture” or “acupuncture therapy” in combination with “ambulatory anesthesia” or “ambulatory surgery” or “day surgery” or “postoperative”. A corresponding search was done using “acupressure” and “wristbands”. The searches generated a total of 104, 118, and 122 references, respectively.Results: Sixteen studies were included; eight studies reported on acupuncture and eight on acupressure. Nine studies found acupuncture or acupressure effective on primary endpoints including postoperative nausea and vomiting, postoperative pain, sore throat, and emergence agitation. Four studies found acupuncture had a similar effect to antiemetic medication.Conclusion: Overall, the studies were of fairly good quality. A large proportion of the reviewed papers highlights an effect of acupuncture or acupressure on postoperative morbidities in an ambulatory setting

  14. Evaluation of health care service quality in Poland with the use of SERVQUAL method at the specialist ambulatory health care center

    Directory of Open Access Journals (Sweden)

    Manulik S

    2016-08-01

    Full Text Available Stanisław Manulik,1 Joanna Rosińczuk,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 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. Keywords: health care service quality, patients’ expectations, qualitative priorities, outpatient health care facilities

  15. Negotiating complementary and alternative medicine use in primary care visits with older patients

    Science.gov (United States)

    Koenig, Christopher J.; Ho, Evelyn Y.; Yadegar, Vivien; Tarn, Derjung M.

    2013-01-01

    Objective To empirically investigate the ways in which patients and providers discuss Complementary and Alternative Medicine (CAM) treatment in primary care visits. Methods Audio recordings from visits between 256 adult patients aged 50 years and older and 28 primary care physicians were transcribed and analyzed using discourse analysis, an empirical sociolinguistic methodology focusing on how language is used to negotiate meaning. Results Discussion about CAM occurred 128 times in 82 of 256 visits (32.0%). The most frequently discussed CAM modalities were non-vitamin, non-mineral supplements and massage. Three physician–patient interactions were analyzed turn-by-turn to demonstrate negotiations about CAM use. Patients raised CAM discussions to seek physician expertise about treatments, and physicians adopted a range of responses along a continuum that included encouragement, neutrality, and discouragement. Despite differential knowledge about CAM treatments, physicians helped patients assess the risks and benefits of CAM treatments and made recommendations based on patient preferences for treatment. Conclusion Regardless of a physician's stance or knowledge about CAM, she or he can help patients negotiate CAM treatment decisions. Practice implications Providers do not have to possess extensive knowledge about specific CAM treatments to have meaningful discussions with patients and to give patients a framework for evaluating CAM treatment use. PMID:22483672

  16. Occupational Therapy Predischarge Home Visits in Acute Hospital Care: A Randomized Trial.

    Science.gov (United States)

    Clemson, Lindy; Lannin, Natasha A; Wales, Kylie; Salkeld, Glenn; Rubenstein, Laurence; Gitlin, Laura; Barris, Sarah; Mackenzie, Lynette; Cameron, Ian D

    2016-10-01

    To determine whether an enhanced occupational therapy discharge planning intervention that involved pre- and postdischarge home visits, goal setting, and follow-up (the HOME program) would be superior to a usual care intervention in which an occupational therapy in-hospital consultation for planning and supporting discharge to home is provided to individuals receiving acute care. Randomized controlled trial. Acute and medical wards. Individuals aged 70 and older (N = 400). Primary outcomes: activities daily living (ADLs; Nottingham Extended Activities of Daily Living) and participation in life roles and activities (Late Life Disability Index (LLDI)). Occupational therapist recommendations differed significantly between groups (P occupational therapy recommendations as the in-hospital only consultation, which had a greater emphasis on equipment provision, but HOME did not demonstrate greater benefit in global measures of ADLs or participation in life tasks than in-hospital consultation alone. It is not recommended that home visits be conducted routinely as part of discharge planning for acutely hospitalized medical patients. Further work should develop guidelines for quality in-hospital consultation. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

  17. Health care and social service professionals' perceptions of a home-visit program for young, first-time mothers.

    Science.gov (United States)

    Li, S A; Jack, S M; Gonzalez, A; Duku, E; MacMillan, H L

    2015-01-01

    Little is known about health care and social service professionals' perspective on the acceptability of long-term home-visit programs serving low-income, first-time mothers. This study describes the experiences and perspectives of these community care providers involved with program referrals or service delivery to mothers who participated in the Nurse-Family Partnership (NFP), a targeted nurse home-visit program. The study included two phases. Phase I was a secondary qualitative data analysis used to analyze a purposeful sample of 24 individual interviews of community care providers. This was part of a larger case study examining adaptations required to increase acceptability of the NFP in Hamilton, Ontario, Canada. In Phase II (n = 4), themes identified from Phase I were further explored through individual, semi-structured interviews with community health care and social service providers, giving qualitative description. Overall, the NFP was viewed as addressing an important service gap for first-time mothers. Providers suggested that frequent communication between the NFP and community agencies serving these mothers could help improve the referral process, avoid service duplication, and streamline the flow of service access. The findings can help determine key components required to enhance the success of integrating a home-visit program into an existing network of community services. The function of home-visit programs should not be viewed in isolation. Rather, their potential can be maximized when they collaborate and share information with other agencies to provide better services for first-time mothers.

  18. Utilization of Rural Primary Care Physicians' Visit Services for Diabetes Management of Public Health in Southwestern China: A Cross-Sectional Study from Patients' View.

    Science.gov (United States)

    Miao, Yudong; Ye, Ting; Qian, Dongfu; Li, Jinlong; Zhang, Liang

    2014-06-01

    Primary care physicians' visit services for diabetes management are now widely delivered in China's rural public health care. Current studies mainly focus on supply but risk factors from patients' view have not been previously explored. This study aims to present the utilization of rural primary care physicians' visit services for diabetes management in the last 12 months in southwestern China, and to explore risk factors from patients' view. This cross sectional study selected six towns at random and all 385 diabetics managed by primary care physicians were potential participants. Basing on the inclusion and exclusion criteria, 374 diabetics were taken as valid subjects and their survey responses formed the data resource of analyses. Descriptive indicators, χ2 contingency table analyses and Logistic regression were used. 54.8% respondents reported the utilization of visit services. According to the multivariate analysis, the positive factors mainly associated with utilization of visit services include disease duration (OR=1.654), use of diabetic drugs (OR=1.869), consulting diabetes care knowledge (OR=1.602), recognition of diabetic complications (OR=1.662), needs of visit services (OR=2.338). The utilization of rural primary care physicians' visit services still remains unsatisfactory. Mass rural health policy awareness, support, and emphasis are in urgent need and possible risk factors including disease duration, use of diabetic drugs, consulting diabetes care knowledge, recognition of diabetic complications and needs of visit services should be taken into account when making rural health policy of visit services for diabetes management in China and many other low- and middle-income countries.

  19. Return-to-Duty Rates Following Minimally Invasive Spine Surgery Performed on Active Duty Military Patients in an Ambulatory Surgery Center.

    Science.gov (United States)

    Granger, Elder; Prada, Stefan; Bereczki, Zoltan; Weiss, Michael; Wade, Chip; Davis, Reginald

    2018-05-21

    Low back pain is a primary health care utilization driver in the US population. Health care evaluation visits for low back pain are as common as medical evaluation for the common cold. Low back pain is the most common reason for reductions in activities of daily living and work activity in the general population. Although these statistics are compelling, in the military population, there is arguably a significantly greater economic impact on the military population, as the cost to train, retain, and deploy a service member is a tremendous cost. The current study retrospectively examines surgical outcomes, return to duty, and patient-centric outcomes among 82 active duty or reserve military patients who underwent an outpatient minimally invasive spine surgery Laminotomy Foraminotomy Decompression for the treatment of lumbar spinal stenosis in an ambulatory surgery center. Overall, our results indicate that within the 82 active duty military service members, 100% of the service members return to duty within 3 mo. Additionally, there was a significant reduction in self-reported pain and disability 12 mo postoperative, whereas the average length of surgery was 62 min with an average estimated blood loss of 30.64 mL. The current study indicates that minimally invasive procedures for the treatment of lumbar spinal stenosis in an ambulatory surgery center setting are an effective option for active duty servicemen to reduce return-to-duty rates and symptomatic back-related pain and disability.

  20. Emergency Department Visits by Older Adults for Motor Vehicle Collisions

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    Vogel, Jody A.

    2013-11-01

    Full Text Available Introduction: To describe the epidemiology and characteristics of emergency department (ED visits by older adults for motor vehicle collisions (MVC in the United States (U.S..Methods: We analyzed ED visits for MVCs using data from the 2003–2007 National Hospital Ambulatory Medical Care Survey (NHAMCS. Using U.S. Census data, we calculated annual incidence rates of driver or passenger MVC-related ED visits and examined visit characteristics, including triage acuity, tests performed and hospital admission or discharge. We compared older (65+ years and younger (18-64 years MVC patients and calculated odds ratios (OR and 95% confidence intervals (CIs to measure the strength of associations between age group and various visit characteristics. Multivariable logistic regression was used to identify independent predictors of admissions for MVC-related injuries among older adults.Results: From 2003–2007, there were an average of 237,000 annual ED visits by older adults for MVCs. The annual ED visit rate for MVCs was 6.4 (95% CI 4.6-8.3 visits per 1,000 for older adults and 16.4 (95% CI 14.0-18.8 visits per 1,000 for younger adults. Compared to younger MVC patients, after adjustment for gender, race and ethnicity, older MVC patients were more likely to have at least one imaging study performed (OR 3.69, 95% CI 1.46-9.36. Older MVC patients were not significantly more likely to arrive by ambulance (OR 1.47; 95% CI 0.76–2.86, have a high triage acuity (OR 1.56; 95% CI 0.77-3.14, or to have a diagnosis of a head, spinal cord or torso injury (OR 0.97; 95% CI 0.42-2.23 as compared to younger MVC patients after adjustment for gender, race and ethnicity. Overall, 14.5% (95% CI 9.8-19.2 of older MVC patients and 6.1% (95% CI 4.8-7.5 of younger MVC patients were admitted to the hospital. There was also a non-statistically significant trend toward hospital admission for older versus younger MVC patients (OR 1.78; 95% CI 0.71-4.43, and admission to the ICU if

  1. Pre-emergency-department care-seeking patterns are associated with the severity of presenting condition for emergency department visit and subsequent adverse events: a timeframe episode analysis.

    Science.gov (United States)

    Chan, Chien-Lung; Lin, Wender; Yang, Nan-Ping; Lai, K Robert; Huang, Hsin-Tsung

    2015-01-01

    Many patients treated in Emergency Department (ED) visits can be treated at primary or urgent care sectors, despite the fact that a number of ED visitors seek other forms of care prior to an ED visit. However, little is known regarding how the pre-ED activity episodes affect ED visits. We investigated whether care-seeking patterns involve the use of health care services of various types prior to ED visits and examined the associations of these patterns with the severity of the presenting condition for the ED visit (EDVS) and subsequent events. This retrospective observational study used administrative data on beneficiaries of the universal health care insurance program in Taiwan. The service type, treatment capacity, and relative diagnosis were used to classify pre-ED visits into 8 care types. Frequent pattern analysis was used to identify sequential care-seeking patterns and to classify 667,183 eligible pre-ED episodes into patterns. Generalized linear models were developed using generalized estimating equations to examine the associations of these patterns with EDVS and subsequent events. The results revealed 17 care-seeking patterns. The EDVS and likelihood of subsequent events significantly differed among patterns. The ED severity index of patterns differ from patterns seeking directly ED care (coefficients ranged from -0.05 to 0.13), and the odds-ratios for the likelihood of subsequent ED visits and hospitalization ranged from 1.18 to 1.86 and 1.16 to 2.84, respectively. The pre-ED care-seeking patterns differ in severity of presenting condition and subsequent events that may represent different causes of ED visit. Future health policy maker may adopt different intervention strategies for targeted population to reduce unnecessary ED visit effectively.

  2. Visita de crianças em unidade de terapia intensiva Children visit to intensive care unit

    Directory of Open Access Journals (Sweden)

    Katya Masae Kitajima Borges

    2010-09-01

    Full Text Available A maioria dos hospitais estabelece idade mínima de 12 anos para a entrada de crianças nas unidades de terapia intensiva de adultos, porém, crianças menores participativas do processo de hospitalização têm manifestado, por meio de seus familiares, o desejo de visitar seus entes hospitalizados. Essa situação suscita diferentes opiniões entre os membros da equipe de saúde, principalmente no que diz respeito a pouca orientação sobre como manejar a entrada de criança na unidade de terapia intensiva sem causar danos psicológicos. Com objetivo de ampliar e fundamentar essa prática realizou-se revisão bibliográfica sobre o tema, alinhada ao estudo das fases do desenvolvimento cognitivo e emocional da criança em relação à compreensão da morte para, em seguida, sugerir proposta para rotina de entrada de crianças em unidade de terapia intensiva adulto.Most hospitals only allow children above 12 years-old to visit adult intensive care unit patients. However, younger children participating in the hospitalization process manifest, through their family members, their willingness to visit their hospitalized relatives. This raises different health care team members' opinions on how to manage their visits to the intensive care unit and prevent psychological harm. Aiming to expand and support this practice, a literature review was conducted, and the children's cognitive and emotional development phases related to understanding of death studied. From this, a routine for children's visits to adult intensive care unit is proposed.

  3. Pre-Emergency-Department Care-Seeking Patterns Are Associated with the Severity of Presenting Condition for Emergency Department Visit and Subsequent Adverse Events: A Timeframe Episode Analysis

    OpenAIRE

    Chan, Chien-Lung; Lin, Wender; Yang, Nan-Ping; Lai, K. Robert; Huang, Hsin-Tsung

    2015-01-01

    Background Many patients treated in Emergency Department (ED) visits can be treated at primary or urgent care sectors, despite the fact that a number of ED visitors seek other forms of care prior to an ED visit. However, little is known regarding how the pre-ED activity episodes affect ED visits. Objectives We investigated whether care-seeking patterns involve the use of health care services of various types prior to ED visits and examined the associations of these patterns with the severity ...

  4. The evolution of ambulatory ECG monitoring.

    Science.gov (United States)

    Kennedy, Harold L

    2013-01-01

    Ambulatory Holter electrocardiographic (ECG) monitoring has undergone continuous technological evolution since its invention and development in the 1950s era. With commercial introduction in 1963, there has been an evolution of Holter recorders from 1 channel to 12 channel recorders with increasingly smaller storage media, and there has evolved Holter analysis systems employing increasingly technologically advanced electronics providing a myriad of data displays. This evolution of smaller physical instruments with increasing technological capacity has characterized the development of electronics over the past 50 years. Currently the technology has been focused upon the conventional continuous 24 to 48 hour ambulatory ECG examination, and conventional extended ambulatory monitoring strategies for infrequent to rare arrhythmic events. However, the emergence of the Internet, Wi-Fi, cellular networks, and broad-band transmission has positioned these modalities at the doorway of the digital world. This has led to an adoption of more cost-effective strategies to these conventional methods of performing the examination. As a result, the emergence of the mobile smartphone coupled with this digital capacity is leading to the recent development of Holter smartphone applications. The potential of point-of-care applications utilizing the Holter smartphone and a vast array of new non-invasive sensors is evident in the not too distant future. The Holter smartphone is anticipated to contribute significantly in the future to the field of global health. © 2013.

  5. Ambulatory Medical Follow-Up in the Year After Surgery and Subsequent Survival in a National Cohort of Veterans Health Administration Surgical Patients.

    Science.gov (United States)

    Schonberger, Robert B; Dai, Feng; Brandt, Cynthia; Burg, Matthew M

    2016-06-01

    Among a national cohort of surgical patients, the authors analyzed the association between medical follow-up during the first postsurgical year and survival during the second postsurgical year. Retrospective cohort study. US Veterans Hospitals. The study included adults who received surgical care in any Veterans Health Administration facility from 2006 to 2011 who were discharged within 10 days of surgery and who survived for at least 1 year postoperatively. None. The association between the receipt of nonsurgical ambulatory medical care during the first postoperative year and the hazard of death during postsurgical year 2 was measured. Among 236,200 veterans, 93.2% received a nonsurgical medical follow-up visit in postsurgical year 1; of those, 5.1% died during postsurgical year 2. This compares with 9.4% year-2 mortality among patients lacking year-1 medical follow-up (p<0.0001). After adjustment for confounders, medical follow-up in postoperative year 1 again was associated with a significantly lower hazard of death in postoperative year 2 (hazard ratio 0.71; 95% confidence interval 0.66-0.78). Sensitivity analyses examining patient subgroups stratified by procedural specialty demonstrated comparable findings. The results were robust under a variety of simulated scenarios of unmeasured confounding. Within a national cohort of US veterans who presented for surgery, those who received nonsurgical ambulatory follow-up during the first postoperative year demonstrated lower all-cause mortality in the subsequent postoperative year than those who did not receive the same type of follow-up care. Interventions focused on postoperative care coordination of outpatient medical follow-up may have the potential to improve long-term postoperative survival. Copyright © 2016. Published by Elsevier Inc.

  6. Gestational Age at First Antenatal Care Visit in Malawi.

    Science.gov (United States)

    Mkandawire, Paul

    2015-11-01

    This paper examines the gestational age at first antenatal care (ANC) visit and factors associated with timely initiation of ANC in Malawi in a context where maternal and child health services are generally provided for free. Lognormal survival models are applied to Demographic and Health Survey data from a nationally representative sample of women (n = 13,588) of child-bearing age. The findings of this study show that less than 30 % of pregnant women initiate ANC within the World Health Organization recommended gestational timeframe of 16 weeks or earlier. The hazard analysis shows a gradient in the initiation of ANC by maternal education level, with least educated mothers most likely to delay their first ANC visit. However, after adjusting for variables capturing intimate partner violence in the multivariate models, the effect of maternal education attenuated and lost statistical significance. Other significant predictors of gestational age at first ANC include media exposure, perceived distance from health facility, age, and birth order. The findings of the study link domestic violence directly with the gestational age at which mothers initiate ANC, suggesting that gender-based violence may operate through delayed initiation of ANC to undermine maternal and child health outcomes.

  7. Admission characteristics, diagnoses and outcomes of HIV-infected patients registered in an ambulatory HIV-care programme in western Kenya.

    Science.gov (United States)

    Siika, A M; Ayuo, P O; Sidle, Mwangi J E; Wools-Kaloustian, K; Kimaiyo, S N; Tierney, W M

    2008-11-01

    To determine admissions diagnosis and outcomes of HIV-infected patients attending AMPATH ambulatory HIV-care clinics. Prospective cohort study. Academic Model for Prevention and Treatment of HIV/ AIDS (AMPATH) ambulatory HIV-care clinic in western Kenya. Between January 2005 and December 2006, 495 HIV-infected patients enrolled in AMPATH were admitted. Median age at admission was 38 years (range: 19-74), 62% females, 375 (76%) initiated cART a median 56 days (range: 1-1288) before admission. Majority (53%) had pre-admission CD4 counts 200 cells/ml. Common admissions diagnoses were: tuberculosis (27%); pneumonia (15%); meningitis (11%); diarrhoea (11%); malaria (6%); severe anaemia (4%); and toxoplasmosis (3%). Deaths occurred in 147 (30%) patients who enrolled at AMPATH a median 44 days (range: 1-711) before admission and died a median 41 days (range: 1-713) after initiating cART. Tuberculosis (27%) and meningitis (14%) were the most common diagnoses in the deceased. Median admission duration was six days (range: 1-30) for deceased patients and eight days (range: 1-44) for survivors (P=0.0024). Deceased patients enrolled in AMPATH or initiated cART more recently, had lower CD4 counts and were more frequently lost to follow-up than survivors (P<0.05 for each comparison). Initiation of cART before admission and clinic appointment adherence were independent predictors of survival. Although high mortality rate is seen in HIV-infected in-patients, those initiating cART before admission were more likely to survive.

  8. Use of Quantile Regression to Determine the Impact on Total Health Care Costs of Surgical Site Infections Following Common Ambulatory Procedures.

    Science.gov (United States)

    Olsen, Margaret A; Tian, Fang; Wallace, Anna E; Nickel, Katelin B; Warren, David K; Fraser, Victoria J; Selvam, Nandini; Hamilton, Barton H

    2017-02-01

    To determine the impact of surgical site infections (SSIs) on health care costs following common ambulatory surgical procedures throughout the cost distribution. Data on costs of SSIs following ambulatory surgery are sparse, particularly variation beyond just mean costs. We performed a retrospective cohort study of persons undergoing cholecystectomy, breast-conserving surgery, anterior cruciate ligament reconstruction, and hernia repair from December 31, 2004 to December 31, 2010 using commercial insurer claims data. SSIs within 90 days post-procedure were identified; infections during a hospitalization or requiring surgery were considered serious. We used quantile regression, controlling for patient, operative, and postoperative factors to examine the impact of SSIs on 180-day health care costs throughout the cost distribution. The incidence of serious and nonserious SSIs was 0.8% and 0.2%, respectively, after 21,062 anterior cruciate ligament reconstruction, 0.5% and 0.3% after 57,750 cholecystectomy, 0.6% and 0.5% after 60,681 hernia, and 0.8% and 0.8% after 42,489 breast-conserving surgery procedures. Serious SSIs were associated with significantly higher costs than nonserious SSIs for all 4 procedures throughout the cost distribution. The attributable cost of serious SSIs increased for both cholecystectomy and hernia repair as the quantile of total costs increased ($38,410 for cholecystectomy with serious SSI vs no SSI at the 70th percentile of costs, up to $89,371 at the 90th percentile). SSIs, particularly serious infections resulting in hospitalization or surgical treatment, were associated with significantly increased health care costs after 4 common surgical procedures. Quantile regression illustrated the differential effect of serious SSIs on health care costs at the upper end of the cost distribution.

  9. Obesity predicts primary health care visits: a cohort study.

    Science.gov (United States)

    Twells, Laurie K; Bridger, Tracey; Knight, John C; Alaghehbandan, Reza; Barrett, Brendan

    2012-02-01

    The objective of this study was to explore the relationship between body mass index (BMI), its association with chronic disease, and its impact on health services utilization in the province of Newfoundland and Labrador, Canada, from 1998 to 2002. A data linkage study was conducted involving a provincial health survey linked to 2 health care use administrative databases. The study population comprised 2345 adults between the ages of 20 and 64 years. Self-reported height and weight measures and other covariates, including chronic diseases, were obtained from a provincial survey. BMI categories include: normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obese class I (BMI 30-34.9), obese class II (BMI ≥ 35), and obese class III (BMI ≥ 40). Survey responses were linked with objective physician and hospital health services utilization over a 5-year period. Weight classifications in the study sample were as follows: 37% normal, 39% overweight, 17% obese, and 6% morbidly obese. The obese and morbidly obese were more likely to report having serious chronic conditions after adjusting for age and sex. Only the morbidly obese group (BMI ≥ 35 kg/m(2)) had a significantly higher number of visits to a general practitioner (GP) over a 5-year period compared to the normal weight group (median 22.0 vs. 17.0, Pchronic conditions and other relevant covariates, being morbidly obese remained a significant predictor of GP visits (Pobesity is placing a burden at the primary health care level. More resources are needed in order to support GPs in their efforts to manage and treat obese adults who have associated comorbidities.

  10. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample.

    Science.gov (United States)

    Newman-Toker, David E; Hsieh, Yu-Hsiang; Camargo, Carlos A; Pelletier, Andrea J; Butchy, Gregary T; Edlow, Jonathan A

    2008-07-01

    To describe the spectrum of visits to US emergency departments (EDs) for acute dizziness and determine whether ED patients with dizziness are diagnosed as having a range of benign and dangerous medical disorders, rather than predominantly vestibular ones. A cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) used a weighted sample of US ED visits (1993-2005) to measure patient and hospital demographics, ED diagnoses, and resource use in cases vs controls without dizziness. Dizziness in patients 16 years or older was defined as an NHAMCS reason-for-visit code of dizziness/vertigo (1225.0) or a final International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of dizziness/vertigo (780.4) or of a vestibular disorder (386.x). A total of 9472 dizziness cases (3.3% of visits) were sampled over 13 years (weighted 33.6 million). Top diagnostic groups were otologic/vestibular (32.9%), cardiovascular (21.1%), respiratory (11.5%), neurologic (11.2%, including 4% cerebrovascular), metabolic (11.0%), injury/poisoning (10.6%), psychiatric (7.2%), digestive (7.0%), genitourinary (5.1%), and infectious (2.9%). Nearly half of the cases (49.2%) were given a medical diagnosis, and 22.1% were given only a symptom diagnosis. Predefined dangerous disorders were diagnosed in 15%, especially among those older than 50 years (20.9% vs 9.3%; Pdisorder in most ED cases and often is associated with cardiovascular or other medical causes, including dangerous ones. Resource use is substantial, yet many patients remain undiagnosed.

  11. Pre-emergency-department care-seeking patterns are associated with the severity of presenting condition for emergency department visit and subsequent adverse events: a timeframe episode analysis.

    Directory of Open Access Journals (Sweden)

    Chien-Lung Chan

    Full Text Available Many patients treated in Emergency Department (ED visits can be treated at primary or urgent care sectors, despite the fact that a number of ED visitors seek other forms of care prior to an ED visit. However, little is known regarding how the pre-ED activity episodes affect ED visits.We investigated whether care-seeking patterns involve the use of health care services of various types prior to ED visits and examined the associations of these patterns with the severity of the presenting condition for the ED visit (EDVS and subsequent events.This retrospective observational study used administrative data on beneficiaries of the universal health care insurance program in Taiwan. The service type, treatment capacity, and relative diagnosis were used to classify pre-ED visits into 8 care types. Frequent pattern analysis was used to identify sequential care-seeking patterns and to classify 667,183 eligible pre-ED episodes into patterns. Generalized linear models were developed using generalized estimating equations to examine the associations of these patterns with EDVS and subsequent events.The results revealed 17 care-seeking patterns. The EDVS and likelihood of subsequent events significantly differed among patterns. The ED severity index of patterns differ from patterns seeking directly ED care (coefficients ranged from -0.05 to 0.13, and the odds-ratios for the likelihood of subsequent ED visits and hospitalization ranged from 1.18 to 1.86 and 1.16 to 2.84, respectively.The pre-ED care-seeking patterns differ in severity of presenting condition and subsequent events that may represent different causes of ED visit. Future health policy maker may adopt different intervention strategies for targeted population to reduce unnecessary ED visit effectively.

  12. Primary care patients' expectations regarding medical appointments and their experiences during a visit: does age matter?

    Directory of Open Access Journals (Sweden)

    Jaworski M

    2017-07-01

    Full Text Available Mariusz Jaworski,1 Marta Rzadkiewicz,1 Miroslawa Adamus,1 Joanna Chylinska,1 Magdalena Lazarewicz,1 Gørill Haugan,2 Monica Lillefjell,3 Geir Arild Espnes,2 Dorota Wlodarczyk1 1Department of Medical Psychology, Second Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland; 2Department of Public Health and Nursing, 3Department of Neuromedicine and Movement Science, NTNU Center for Health Promotion Research, Norwegian University of Science and Technology, Trondheim, Norway Introduction: There is evidence that meeting patients’ expectations toward health care correlates with involvement in the treatment they receive. The most important patient expectations concern certain types of information: explanation of disease and treatment, health promotion, and improvement in quality of life. Other demands include proper rapport and emotional support. The aim of this paper was to examine different patient groups over the age of 50 years and their expectations toward medical visits, evaluated before a visit and after the visit.Patients and methods: The study group consisted of 4,921 primary health-care patients. The patients received self-administered questionnaires that they filled in before and after the appointment with the doctor. Interviews with patients were conducted individually by specially trained interviewers. The PRACTA Patient Expectations Scale was used to measure the appointment-related expectations of the patients.Results: We observed differences related to age in patients’ expectations before medical visits regarding the following factors: disease explanation, treatment explanation, quality of life, rapport, and emotional support. The same differences were not observed on health promotion. Evaluation of patients’ appointment-related experiences after the visit showed that there were significant differences between the age-groups regarding all types of expectations included in the study. Differences between previsit and

  13. Impact of Diabetes Care by Pharmacists as Part of Health Care Team in Ambulatory Settings: A Systematic Review and Meta-analysis.

    Science.gov (United States)

    Fazel, Maryam T; Bagalagel, Alaa; Lee, Jeannie K; Martin, Jennifer R; Slack, Marion K

    2017-10-01

    To conduct a comprehensive systematic review and meta-analyses examining the impact of pharmacist interventions as part of health care teams on diabetes therapeutic outcomes in ambulatory care settings. PubMed/MEDLINE, EMBASE, Cochrane Library, International Pharmaceutical Abstracts, Web of Science, Scopus, WHO's Global Health Library, ClinicalTrials.gov , and Google Scholar were searched (1995 to February 2017). Search terms included pharmacist, team, and diabetes. Full-text articles published in English with comparative designs, including randomized controlled trials, nonrandomized controlled trials, and pretest-posttest studies evaluating hemoglobin A 1C (A1C), were assessed. Two reviewers independently screened for study inclusion and extracted data. Quality of the studies was assessed using tools developed based on the framework of the Cochrane Collaboration's recommendations. A total of 1908 studies were identified from the literature and reference searches; 42 studies were included in the systematic review (n = 10 860) and 35 in the meta-analyses (n = 7417). Mean age ranged from 42 to 73 years, and 8% to 100% were male. The overall standardized mean difference (SMD) for A1C for pharmacist care versus comparison was 0.57 ( P 83%), indicating functional differences among the studies. No publication bias was detected. Pharmacists' interventions as part of the patient's health care team improved diabetes therapeutic outcomes, substantiating the important role of pharmacists in team-based diabetes management.

  14. Capitated payments to primary care providers and the delivery of patient education.

    Science.gov (United States)

    Pearson, William S; King, Dana E; Richards, Chesley

    2013-01-01

    Patient education is a critical component of the patient-centered medical home and is a powerful and effective tool in chronic disease management. However, little is known about the effect of practice payment on rates of patient education during office encounters. For this study we took data from the 2009 National Ambulatory Medical Care Survey. This was a cross-sectional analysis of patient visits to primary care providers to determine whether practice payment in the form of capitated payments is associated within patient education being included more frequently during office visits compared with other payment methods. In a sample size of 9863 visits in which capitation status was available and the provider was the patient's primary care provider, the weighted percentages of visits including patient education were measured as a percentages of education (95% confidence intervals): 75% capitation, 74.0% (52.2-88.1). In an adjusted logistic model controlling for new patients (yes/no), number of chronic conditions, number of medications managed, number of previous visits within the year, and age and sex of the patients, the odds of receiving education were reported as odds ratios (95% confidence intervals): 75% capitation, 3.38 (1.23-9.30). Patients are more likely to receive education if their primary care providers receive primarily capitated payment. This association is generally important for health policymakers constructing payment strategies for patient populations who would most benefit from interventions that incorporate or depend on patient education, such as populations requiring management of chronic diseases.

  15. High Health Care Utilization Preceding Diagnosis of Systemic Lupus Erythematosus in Youth.

    Science.gov (United States)

    Chang, Joyce C; Mandell, David S; Knight, Andrea M

    2017-12-01

    Childhood-onset systemic lupus erythematosus (SLE) is associated with high risk for organ damage, which may be mitigated by early diagnosis and treatment. We characterized health care utilization for youth in the year preceding SLE diagnosis compared to controls. Using Clinformatics ™ DataMart (OptumInsight, Eden Prairie, MN) de-identified administrative data from 2000 to 2013, we identified 682 youth ages 10-24 years with new-onset SLE (≥3 International Classification of Diseases, Ninth Revision (ICD-9) codes for SLE 710.0, each >30 days apart), and 1,364 age and sex-matched healthy controls. We compared the incidence of ambulatory, emergency, and inpatient visits 12 months before SLE diagnosis, and frequency of primary diagnoses. We examined subject characteristics associated with utilization preceding SLE diagnosis. Youth with SLE had significantly more visits in the year preceding diagnosis than controls across ambulatory (incidence rate ratio (IRR) 2.48, p<0.001), emergency (IRR 3.42, p<0.001) and inpatient settings (IRR 3.02, p<0.001). The most frequent acute care diagnoses and median days to SLE diagnosis were: venous thromboembolism (313, interquartile range (IQR) 18-356), thrombocytopenia (278, IQR 39-354), chest pain (73, IQR 29.5-168), fever (52, IQR 17-166), and acute kidney failure (14, IQR 5-168). Having a psychiatric diagnosis prior to SLE diagnosis was strongly associated with increased utilization across all settings. Youth with SLE have high health care utilization throughout the year preceding SLE diagnosis. Examining variable diagnostic trajectories of youth presenting for acute care preceding SLE diagnosis, and increased attention to psychiatric morbidity may help improve care for youth with new-onset SLE. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

  16. Society for Ambulatory Anesthesia

    Science.gov (United States)

    ... SAMBA Link Digital Newsletter Educational Bibliography Research IARS/Anesthesia & Analgesia SCOR About SCOR Sponsor SAMBA Meetings Affinity Sponsor Program We Represent Ambulatory and Office-Based Anesthesia The Society for Ambulatory Anesthesia provides educational opportunities, ...

  17. Analysis of team types based on collaborative relationships among doctors, home-visiting nurses and care managers for effective support of patients in end-of-life home care.

    Science.gov (United States)

    Fujita, Junko; Fukui, Sakiko; Ikezaki, Sumie; Otoguro, Chizuru; Tsujimura, Mayuko

    2017-11-01

    To define the team types consisting of doctors, home-visiting nurses and care managers for end-of-life care by measuring the collaboration relationship, and to identify the factors related to the team types. A questionnaire survey of 43 teams including doctors, home-visiting nurses and care managers was carried out. The team types were classified based on mutual evaluations of the collaborative relationships among the professionals. To clarify the factors between team types with the patient characteristics, team characteristics and collaboration competency, univariate analysis was carried out with the Fisher's exact test or one-way analysis and multiple comparison analysis. Three team types were classified: the team where the collaborative relationships among all healthcare professionals were good; the team where the collaborative relationships between the doctors and care managers were poor; and the team where the collaborative relationships among all of the professionals were poor. There was a statistically significant association between the team types and the following variables: patient's dementia level, communication tool, professionals' experience of working with other team members, home-visiting nurses' experience of caring for dying patients, care managers' background qualifications, doctor's face-to-face cooperation with other members and home-visiting nurses' collaborative practice. It is suggested that a collaborative relationship would be fostered by more experience of working together, using communication tools and enhancing each professional's collaboration competency. Geriatr Gerontol Int 2017; 17: 1943-1950. © 2017 Japan Geriatrics Society.

  18. Patterns of opioid initiation at first visits for pain in United States primary care settings.

    Science.gov (United States)

    Mundkur, Mallika L; Rough, Kathryn; Huybrechts, Krista F; Levin, Raisa; Gagne, Joshua J; Desai, Rishi J; Patorno, Elisabetta; Choudhry, Niteesh K; Bateman, Brian T

    2018-05-01

    The primary objective of this study was to characterize variation in patterns of opioid prescribing within primary care settings at first visits for pain, and to describe variation by condition, geography, and patient characteristics. 2014 healthcare utilization data from Optum's Clinformatics™ DataMart were used to evaluate individuals 18 years or older with an initial presentation to primary care for 1 of 10 common pain conditions. The main outcomes assessed were (1) the proportion of first visits for pain associated with an opioid prescription fill and (2) the proportion of opioid prescriptions with >7 days' supply. We identified 205 560 individuals who met inclusion criteria; 9.1% of all visits were associated with an opioid fill, ranging from 4.1% (headache) to 28.2% (dental pain). Approximately half (46%) of all opioid prescriptions supplied more than 7 days, and 10% of prescriptions supplied ≥30 days. We observed a 4-fold variation in rates of opioid initiation by state, with highest rates of prescribing in Alabama (16.6%) and lowest rates in New York (3.7%). In 2014, nearly half of all patients filling opioid prescriptions received more than 7 days' of opioids in an initial prescription. Policies limiting initial supplies have the potential to substantially impact opioid prescribing in the primary care setting. Copyright © 2017 John Wiley & Sons, Ltd.

  19. Special article: Creation of a guide for the transfer of care of the malignant hyperthermia patient from ambulatory surgery centers to receiving hospital facilities.

    Science.gov (United States)

    Larach, Marilyn Green; Dirksen, Sharon J Hirshey; Belani, Kumar G; Brandom, Barbara W; Metz, Keith M; Policastro, Michael A; Rosenberg, Henry; Valedon, Arnaldo; Watson, Charles B

    2012-01-01

    Volatile anesthetics and/or succinylcholine may trigger a potentially lethal malignant hyperthermia (MH) event requiring critical care crisis management. If the MH triggering anesthetic is given in an ambulatory surgical center (ASC), then the patient will need to be transferred to a receiving hospital. Before May 2010, there was no clinical guide regarding the development of a specific transfer plan for MH patients in an ASC. MECHANISM BY WHICH THE STATEMENT WAS GENERATED: A consensual process lasting 18 months among 13 representatives of the Malignant Hyperthermia Association of the United States, the Ambulatory Surgery Foundation, the Society for Ambulatory Anesthesia, the Society for Academic Emergency Medicine, and the National Association of Emergency Medical Technicians led to the creation of this guide. EVIDENCE FOR THE STATEMENT: Most of the guide is based on the clinical experience and scientific expertise of the 13 representatives. The list of representatives appears in Appendix 1. The recommendation that IV dantrolene should be initiated pending transfer is also supported by clinical research demonstrating that the likelihood of significant MH complications doubles for every 30-minute delay in dantrolene administration (Anesth Analg 2010;110:498-507). This guide includes a list of potential clinical problems and therapeutic interventions to assist each ASC in the development of its own unique MH transfer plan. Points to consider include receiving health care facility capabilities, indicators of patient stability and necessary report data, transport team considerations and capabilities, implementation of transfer decisions, and coordination of communication among the ASC, the receiving hospital, and the transport team. See Appendix 2 for the guide.

  20. The Value Proposition of Prevention: The Impacts of Pure North S’Energy Foundation’s Preventive Care Program on Acute Care Utilization in Alberta

    Directory of Open Access Journals (Sweden)

    J.C. Herbert Emery

    2016-04-01

    and the number of visits for ambulatory care reduced by 14 per cent over a control group matched for age, sex and postal code, who did not participate in the Pure North program. In the second year after joining the program, hospital admissions dropped by 32 per cent for participants aged 55 and over. If these effects could be achieved in the population of Albertans aged 55 to 75, the hospital bed nights freed up per year would be equivalent to adding the acute care bed capacity of the Foothills Medical Centre in Calgary. These figures translate into significant cost differences. The average cost of hospitals, ambulatory care and visits to general practitioners in the year prior to joining Pure North’s program came to $1,320 per individual. Cost reductions in annual health-care utilization among participants ranged from $294 (22 per cent per person who joined the program to $600 (45 per cent per person who stayed in the program for at least a year. Two years into the program, a participant could expect to avoid $276 in hospitalization and emergency room costs. The Pure North program is a cost-effective model for preventive health services, resulting in better health and labour productivity for individuals, and considerable savings in public money for the health-care system. Every dollar spent on a participant who stays with the program for at least a year represents a $2.36 benefit in the avoidance of hospitalization and ambulatory care, as well as gains in personal health and productivity. The public health-care system must shift its focus to preventive care if it wants to realize cost savings, efficiency and improved health for Albertans, rather than waiting to treat people until after they become ill with chronic diseases. Pure North offers an important model to help the public system understand how to make that transition to a prevention-oriented mindset.

  1. Safety and cost benefit of an ambulatory program for patients with low-risk neutropenic fever at an Australian centre.

    Science.gov (United States)

    Teh, Benjamin W; Brown, Christine; Joyce, Trish; Worth, Leon J; Slavin, Monica A; Thursky, Karin A

    2018-03-01

    Neutropenic fever (NF) is a common complication of cancer chemotherapy. Patients at low risk of medical complications from NF can be identified using a validated risk assessment and managed in an outpatient setting. This is a new model of care for Australia. This study described the implementation of a sustainable ambulatory program for NF at a tertiary cancer centre over a 12-month period. Peter MacCallum Cancer Centre introduced an ambulatory care program in 2014, which identified low-risk NF patients, promoted early de-escalation to oral antibiotics, and early discharge to a nurse-led ambulatory program. Patients prospectively enrolled in the ambulatory program were compared with a historical-matched cohort of patients from 2011 for analysis. Patient demographics, clinical variables (cancer type, recent chemotherapy, treatment intent, site of presentation) and outcomes were collected and compared. Total cost of inpatient admissions was determined from diagnosis-related group (DRG) codes and applied to both the prospective and historical cohorts to allow comparisons. Twenty-five patients were managed in the first year of this program with a reduction in hospital median length of stay from 4.0 to 1.1 days and admission cost from Australian dollars ($AUD) 8580 to $AUD2360 compared to the historical cohort. Offsetting salary costs, the ambulatory program had a net cost benefit of $AUD 71895. Readmission for fever was infrequent (8.0%), and no deaths were reported. Of relevance to hospitals providing cancer care, feasibility, safety, and cost benefits of an ambulatory program for low-risk NF patients have been demonstrated.

  2. Mental health treatment associated with community-based depression screening: considerations for planning multidisciplinary collaborative care.

    Science.gov (United States)

    Winchester, Bruce R; Watkins, Sarah C; Brahm, Nancy C; Harrison, Donald L; Miller, Michael J

    2013-06-01

    Depression places a large economic burden on the US health care system. Routine screening has been recognized as a fundamental step in the effective treatment of depression, but should be undertaken only when support systems are available to ensure proper diagnosis, treatment, and follow-up. To estimate differences in prescribing new antidepressants and referral to stress management, psychotherapy, and other mental health (OMH) counseling at physician visits when documented depression screening was and was not performed. Cross-sectional physician visit data for adults from the 2005-2007 National Ambulatory Medical Care Survey were used. The final analytical sample included 55,143 visits, representing a national population estimate of 1,741,080,686 physician visits. Four dependent variables were considered: (1) order for new antidepressant(s), and referral to (2) stress management, (3) psycho therapy, or (4) OMH counseling. Bivariable and multivariable associations between depression screening and each measure of depression follow-up care were evaluated using the design-based F statistic and multivariable logistic regression models. New antidepressant prescribing increased significantly (2.12% of visits without depression screening vs 10.61% with depression screening resulted in a new prescription of an antidepressant). Referral to stress management was the behavioral treatment with the greatest absolute change (3.31% of visits without depression screening vs 33.10% of visits with depression screening resulted in a referral to stress management). After controlling for background sociodemographic characteristics, the adjusted odds ratio of a new antidepressant order remained significantly higher at visits involving depression screening (AOR 5.36; 99.9% CI 2.92-9.82), as did referrals for all behavioral health care services (ie, stress management, psychotherapy, and OMH counseling). At the national level, depression screening was associated with increased new

  3. Effect of Ambulatory Transitional Care Management on 30-Day Readmission Rates.

    Science.gov (United States)

    Ballard, Jonathan; Rankin, Wade; Roper, Karen L; Weatherford, Sarah; Cardarelli, Roberto

    2018-05-01

    A process improvement initiative for transitional care management (TCM) was evaluated for effectiveness in reducing 30-day readmission rates in a retrospective cohort study. Regression models analyzed the association between level of TCM component implementation and readmission rates among patients discharged from a university medical center hospital. Of the 1884 patients meeting inclusion criteria, only 3.7% (70) experienced a 30-day readmission. Patients receiving the full complement of TCM had 86.6% decreased odds of readmission compared with patients who did not receive TCM ( P < .001). However, the complete package of TCM services under Medicare guidelines may not be essential. A postdischarge telephone call did not reduce readmission odds, provided a TCM office visit occurred. Important for risk assessment models targeting patients for TCM, the number of previous hospital admissions, not age, predicted 30-day readmission risk. This study provides evidence that primary care-based TCM can reduce 30-day readmissions even when overall rates are low.

  4. Ambulatory surgery centers and interventional techniques: a look at long-term survival.

    Science.gov (United States)

    Manchikanti, Laxmaiah; Parr, Allan T; Singh, Vijay; Fellows, Bert

    2011-01-01

    With health care expenditures skyrocketing, coupled with pervasive quality deficits, pressures to provide better and more proficient care continue to shape the landscape of the U.S. health care system. Payers, both federal and private, have laid out several initiatives designed to curtail costs, including value-based reimbursement programs, cost-shifting expenses to the consumer, reducing reimbursements for physicians, steering health care to more efficient settings, and finally affordable health care reform. Consequently, one of the major aspects in the expansion of health care for improving quality and reducing the costs is surgical services. Nearly 57 million outpatient procedures are performed annually in the United States, 14 million of which occur in elderly patients. Increasing use of these minor, yet common, procedures contributes to rising health care expenditures. Once exclusive within hospitals, more and more outpatient procedures are being performed in freestanding ambulatory surgery centers (ASCs), physician offices, visits to which have increased over 300% during the past decade. Concurrent with this growing demand, the number of ASCs has more than doubled since the 1990s, with more than 5,000 facilities currently in operation nationwide. Further, total surgical center ASC payments have increased from $1.2 billion in 1999 to $3.2 billion in 2009, a 167% increase. On the same lines, growth and expenditures for hospital outpatient department (HOPD) services and office procedures also have been evident at similar levels. Recent surveys have illustrated on overall annual growth per capita in Medicare allowed ASC services of pain management of 23%, with 27% growth seen in ASCs and 16% of the growth seen in HOPD. Further, the proportion of interventional pain management which was 4% of Medicare ASC spending in 2000 has increase to 10% in 2007. Thus, interventional pain management as an evolving specialty is one of the most commonly performed procedures in

  5. Home hospitalization in the spectrum of community geriatric care.

    Science.gov (United States)

    Stessman, J; Hammerman-Rozenberg, R; Cohen, A

    1997-04-01

    The Home Hospitalization Programme was initiated in Jerusalem in 1991 to provide intensive medical care at home in order to prevent or shorten hospitalizations. The programme was based upon regular home visits by physicians, and nursing assessment to determine the need for regular nursing care. Primary-care physicians and nurses were renumerated by a global monthly fee, and were on 24-h call in addition to their periodic visits. Patients were recruited by senior geriatric physicians from acute hospital wards, as well as from the community, at the family doctor's request. Ancillary services available to the home hospitalization team included laboratory and electrocardiographic testing, specialty consultations, physical occupational or speech therapy, social work and home help up to 3 h daily. Monthly visits by a senior physician provided oversight and further consultation. Home hospitalization grew out of the continuing care division of the Clalit Sick Fund, a health maintenance organization providing umbrella medical insurance and ambulatory care. The programme grew synergistically with the other facilities of continuing care to encompass a network of comprehensive services to acute, subacute and chronic patients both at home and in institutional settings. In 4 years this network succeeded in establishing the focus of subacute intensive care in the community, achieving high levels of patient and family satisfaction, as well as striking economic advantages. In its first 2 years of operation home hospitalization saved S4 million due to reduced hospital utilization, and preliminary data for the subsequent 2 years indicated that this trend continued. Home hospitalization became the hub of a far-reaching system of supportive, intensive and humane care in the community.

  6. A Comparison of Ambulatory Care Sensitive Hospitalizations Among Children With and Without Autism Spectrum Disorder.

    Science.gov (United States)

    Carbone, Paul S; Young, Paul C; Stoddard, Gregory J; Wilkes, Jacob; Trasande, Leonardo

    2015-01-01

    To compare the prevalence of hospitalizations for ambulatory care sensitive conditions (ACSC) in children with and without autism spectrum disorder (ASD) and to compare inpatient health care utilization (total charges and length of stay) for the same conditions in children with and without ASD. The 2009 Kids' Inpatient Database was used to examine hospitalizations for ACSC in children within 3 cohorts: those with ASD, those with chronic conditions (CC) without ASD, and those with no CC. The proportion of hospitalizations for ACSC in the ASD cohort was 55.9%, compared with 28.2% in the CC cohort and 22.9% in the no-CC cohort (P Hospitalized children with ASD were more likely to be admitted for a mental health condition, epilepsy, constipation, pneumonia, dehydration, vaccine-preventable diseases, underweight, and nutritional deficiencies compared with the no-CC cohort. Compared with the CC cohort, the ASD cohort was more likely to be admitted for mental health conditions, epilepsy, constipation, dehydration, and underweight. Hospitalized children with ASD admitted for mental health conditions had significantly higher total charges and longer LOS compared with the other 2 cohorts. The proportion of potentially preventable hospitalizations is higher in hospitalized children with ASD compared with children without ASD. These data underscore the need to improve outpatient care of children with ASD, especially in the areas of mental health care and seizure management. Future research should focus on understanding the reasons for increased inpatient health care utilization in children with ASD admitted for mental health conditions. Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

  7. Collecting Practice-level Data in a Changing Physician Office-based Ambulatory Care Environment: A Pilot Study Examining the Physician induction interview Component of the National Ambulatory Medical Care Survey.

    Science.gov (United States)

    Halley, Meghan C; Rendle, Katharine A; Gugerty, Brian; Lau, Denys T; Luft, Harold S; Gillespie, Katherine A

    2017-11-01

    Objective This report examines ways to improve National Ambulatory Medical Care Survey (NAMCS) data on practice and physician characteristics in multispecialty group practices. Methods From February to April 2013, the National Center for Health Statistics (NCHS) conducted a pilot study to observe the collection of the NAMCS physician interview information component in a large multispecialty group practice. Nine physicians were randomly sampled using standard NAMCS recruitment procedures; eight were eligible and agreed to participate. Using standard protocols, three field representatives conducted NAMCS physician induction interviews (PIIs) while trained ethnographers observed and audio recorded the interviews. Transcripts and field notes were analyzed to identify recurrent issues in the data collection process. Results The majority of the NAMCS items appeared to have been easily answered by the physician respondents. Among the items that appeared to be difficult to answer, three themes emerged: (a) physician respondents demonstrated an inconsistent understanding of "location" in responding to questions; (b) lack of familiarity with administrative matters made certain questions difficult for physicians to answer; and (c) certain primary care‑oriented questions were not relevant to specialty care providers. Conclusions Some PII survey questions were challenging for physicians in a multispecialty practice setting. Improving the design and administration of NAMCS data collection is part of NCHS' continuous quality improvement process. All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

  8. Side effects after ambulatory lumbar iohexol myelography

    International Nuclear Information System (INIS)

    Sand, T.; Myhr, G.; Stovner, L.J.; Dale, L.G.; Tangerud, A.

    1989-01-01

    Side effect incidences after ambulatory (22G needle and two h bed rest) and after non-ambulatory (22 and 20G needles and 20 h bed rest) lumbar iohexol myelography have been estimated and compared. Headache incidence was significantly greater in ambulatory (50%, n=107) as compared to nonambulatory myelography (26%, n=58). Headaches in the ambulatory group tended to be of shorter duration and the difference between severe headaches in ambulatory and non-ambulatory groups was not significant. Serious adverse reactions did not occur and none of the ambulatory patients required readmission because of side effects. The headache was predominantly postural and occurred significantly earlier in the ambulatory group. Headache incidence was significantly greater after 20G needle myelography (44%, n=97) as compared to 22G needle iohexol myelography (26%, n=58). The results support the hypothesis that CSF leakage is a major cause of headache after lumbar iohexol myelography. (orig.)

  9. Utilization of the out of hours service in Poland: an observational study from Krakow

    Directory of Open Access Journals (Sweden)

    Tomasik Tomasz

    2008-10-01

    Full Text Available Abstract Background In 2000 a new GP contract was introduced in Poland. It allowed GPs to subcontract out of hours care to specialized deputizing services. One such service in Kraków provides care to 61 GP practices with a population of 420 000 inhabitants. The aim of this study is to analyze seasonal and geographical variation in out of hours care use and to find the most important factors influencing it. Methods Routinely collected data for 24 months (2003–2004 containing type, date and time of the contacts were used. Results During the study period 238 072 contacts were recorded: 149 911 ambulatory doctor visits, 23 434 home visits and 64 727 nurse procedures. The mean rate of out of hours contacts was: for ambulatory visits 178 per 1000 inhabitants/year (varied between practices from 9 to 696, for home visits 28 (from 1 to 36 and for nurse procedures 77 (from 3 to 327. The highest rate of ambulatory visits was 739 in the age group 0–4, the lowest – 104 in the age group 45–49. The highest rate of home visits was 221 in the age group over 85. The rate of ambulatory GP visits and nurse procedures was negatively correlated with the distance between the location of GP practice and the nearest out of hours clinic. The rate of home visits was positively correlated with the age of the patient. Conclusion Significant differences between practices suggest that non medical factors may play an important role in the patient's decision to see a GP when the surgery is closed. Their influence should be limited to make the system more efficient.

  10. Ambulatory surgery and anaesthesia in HUKM, a teaching hospital in Malaysia: the first two years experience.

    Science.gov (United States)

    Norsidah, A M; Yahya, N; Adeeb, N; Lim, A L

    2001-03-01

    Ambulatory or day care surgery is still in its infancy in this part of the world. Our newly built university affiliated hospital started its Day Surgery Centre in February 1998. It is the first multidisciplinary ambulatory surgery centre in a teaching hospital in the country. It caters for Orthopaedic surgery, Urology, Plastic surgery, Otorhinolaryngology, General surgery, Paediatric surgery and Ophthalmology. We have done 2,604 cases and our unanticipated admission rate is less than 2%. There has been no major morbidity or mortality. The problems of setting up a multidisciplinary ambulatory centre in a teaching hospital are discussed.

  11. Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices: A Modeling Study.

    Science.gov (United States)

    Basu, Sanjay; Phillips, Russell S; Bitton, Asaf; Song, Zirui; Landon, Bruce E

    2015-10-20

    Physicians have traditionally been reimbursed for face-to-face visits. A new non-visit-based payment for chronic care management (CCM) of Medicare patients took effect in January 2015. To estimate financial implications of CCM payment for primary care practices. Microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements. National Ambulatory Medical Care Survey and other published sources. Medicare patients. 10 years. Practice-level. Comparison of CCM delivery approaches by staff and physicians. Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services. If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 ,00 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services. If physicians were to deliver all CCM services, approximately 25% of practices nationwide could expect net revenue losses due to opportunity costs of face-to-face visit time. The CCM program may alter long-term primary care use, which is difficult to predict. Practices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs. None.

  12. Hospitalisations and costs relating to ambulatory care sensitive conditions in Ireland.

    LENUS (Irish Health Repository)

    Sheridan, A

    2012-03-08

    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 267.8 million in 2005 to 352.2 million in 2008. Across the country, there was considerable variation in the discharge rates for the Top-10 ACSCs for the years 2005-2008. Significantly lower rates of hospitalisation were observed in more urban areas including Cork, Dublin and Galway. The most common ACSC in 2008 was diabetes with complications (29.8%). CONCLUSIONS: The variation in rates observed indicates the scope of reducing hospitalisations and associated costs for ACSCs, across both adult\\'s and children\\'s services and particularly in relation to diabetes complications.

  13. Diagnostic value and cost-benefit analysis of 24 hours ambulatory blood pressure monitoring in primary care in Portugal

    Science.gov (United States)

    2013-01-01

    Background Hypertensive patients (HTs) are usually attended in primary care (PC). We aimed to assess the diagnostic accuracy and cost-benefit ratio of 24-hour ambulatory blood pressure monitoring (ABPM) in all newly diagnosed hypertensive patients (HTs) attended in PC. Methods In a cross-sectional study ABPM was recorded in all 336 never treated HTs (Office BP ≥140 and/or ≥ 90 mm Hg) that were admitted during 16 months. Since benefits from drug treatment in white-coat hypertension (WCH) remain unproven, a cost benefit estimation of a general use of ABPM (vs absence of ABPM) in HTs was calculated comparing the cost of usual medical assistance of HTs only diagnosed in office with that based both on refraining from drug treatment all subjects identified as WCH and on the reduction by half of the frequency of biochemical exams and doctor visits. Results Women were 56%, age 51 ± 14 years and BMI 27 ± 4 Kg/m2. Out of these, 206 were considered as true HTs, daytime ABPM ≥ 135 and/or ≥85 mm Hg and 130 (38,7%) were identified as having white coat hypertension (WCH), daytime ABPM ABPM total medical expenses can be reduced by 23% (157.500 euros) with a strategy based on ABPM for 1000 patients followed for 2 years. Conclusions In PC, the widespread use of ABPM in newly diagnosed HTs increases diagnostic accuracy of hypertension, improves cardiovascular risk stratification, reduces health expenses showing a highly favourable benefit-cost ratio vs a strategy without ABPM. PMID:23937261

  14. Service quality and patient experiences of ambulatory care in a specialized clinic vs. a general hospital.

    Science.gov (United States)

    De Regge, Melissa; De Groote, Hélène; Trybou, Jeroen; Gemmel, Paul; Brugada, Pedro

    2017-04-01

    Health care organizations are constantly looking for ways to establish a differential advantage to attract customers. To this end, service quality has become an important differentiator in the strategy of health care organizations. In this study, we compared the service quality and patient experience in an ambulatory care setting of a physician-owned specialized facility with that of a general hospital. A comparative case study with a mixed method design was employed. Data were gathered through a survey on health service quality and patient experience, completed with observations, walkthroughs, and photographic material. Service quality and patient experiences are high in both the investigated health care facilities. A significant distinction can be made between the two facilities in terms of interpersonal quality (p = 0.001) and environmental quality (P ≤ 0.001), in favor of the medical center. The difference in environmental quality is also indicated by the scores given by participants who had been in both facilities. Qualitative analysis showed higher administrative quality in the medical center. Environmental quality and patient experience can predict the interpersonal quality; for environmental quality, interpersonal quality and age are significant predictors. Service quality and patient experiences are high in both facilities. The medical center has higher service quality for interpersonal and environmental service quality and is more process-centered.

  15. Ambulatory heart rate is underestimated when measured by an Ambulatory Blood Pressure device

    NARCIS (Netherlands)

    Vrijkotte, T.G.M.; de Geus, E.J.C.

    1999-01-01

    Objective: To test the validity of ambulatory heart rate (HR) assessment with a cuff ambulatory blood pressure (ABP) monitor. Design: Cross-instrument comparison of HR measured intermittently by a cuff ABP monitor (SpaceLabs, Redmond, Washington, USA), with HR derived from continuous

  16. Ambulatory heart rate is underestimated when measured by an ambulatory blood pressure device

    NARCIS (Netherlands)

    Vrijkotte, T. G.; de Geus, E. J.

    2001-01-01

    To test the validity of ambulatory heart rate (HR) assessment with a cuff ambulatory blood pressure (ABP) monitor. Cross-instrument comparison of HR measured intermittently by a cuff ABP monitor (SpaceLabs, Redmond, Washington, USA), with HR derived from continuous electrocardiogram (ECG) recordings

  17. Ambulatory heart rate is underestimated when measured by an ambulatory blood pressure device

    NARCIS (Netherlands)

    Vrijkotte, T.G.M.; de Geus, E.J.C.

    2001-01-01

    Objective: To test the validity of ambulatory heart rate (HR) assessment with a cuff ambulatory blood pressure (ABP) monitor. Design: Cross-instrument comparison of HR measured intermittently by a cuff ABP monitor (SpaceLabs, Redmond, Washington, USA), with HR derived from continuous

  18. Timing and adequate attendance of antenatal care visits among women in Ethiopia.

    Directory of Open Access Journals (Sweden)

    Sanni Yaya

    Full Text Available Although ANC services are increasingly available to women in low and middle-income countries, their inadequate use persists. This suggests a misalignment between aims of the services and maternal beliefs and circumstances. Owing to the dearth of studies examining the timing and adequacy of content of care, this current study aims to investigate the timing and frequency of ANC visits in Ethiopia.Data was obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS which used a two-stage cluster sampling design to provide estimates for the health and demographic variables of interest for the country. Our study focused on a sample of 10,896 women with history of at least one childbirth event. Percentages of timing and adequacy of ANC visits were conducted across the levels of selected factors. Variables which were associated at 5% significance level were examined in the multivariable logistic regression model for association between timing and frequency of ANC visits and the explanatory variables while controlling for covariates. Furthermore, we presented the approach to estimate marginal effects involving covariate-adjusted logistic regression with corresponding 95%CI of delayed initiation of ANC visits and inadequate ANC attendance. The method used involved predicted probabilities added up to a weighted average showing the covariate distribution in the population.Results indicate that 66.3% of women did not use ANC at first trimester and 22.3% had ANC less than 4 visits. The results of this study were unique in that the association between delayed ANC visits and adequacy of ANC visits were examined using multivariable logistic model and the marginal effects using predicted probabilities. Results revealed that older age interval has higher odds of inadequate ANC visits. More so, type of place of residence was associated with delayed initiation of ANC visits, with rural women having the higher odds of delayed

  19. Timing and adequate attendance of antenatal care visits among women in Ethiopia

    Science.gov (United States)

    Bishwajit, Ghose; Ekholuenetale, Michael; Shah, Vaibhav; Kadio, Bernard; Udenigwe, Ogochukwu

    2017-01-01

    Introduction Although ANC services are increasingly available to women in low and middle-income countries, their inadequate use persists. This suggests a misalignment between aims of the services and maternal beliefs and circumstances. Owing to the dearth of studies examining the timing and adequacy of content of care, this current study aims to investigate the timing and frequency of ANC visits in Ethiopia. Methods Data was obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS) which used a two-stage cluster sampling design to provide estimates for the health and demographic variables of interest for the country. Our study focused on a sample of 10,896 women with history of at least one childbirth event. Percentages of timing and adequacy of ANC visits were conducted across the levels of selected factors. Variables which were associated at 5% significance level were examined in the multivariable logistic regression model for association between timing and frequency of ANC visits and the explanatory variables while controlling for covariates. Furthermore, we presented the approach to estimate marginal effects involving covariate-adjusted logistic regression with corresponding 95%CI of delayed initiation of ANC visits and inadequate ANC attendance. The method used involved predicted probabilities added up to a weighted average showing the covariate distribution in the population. Results Results indicate that 66.3% of women did not use ANC at first trimester and 22.3% had ANC less than 4 visits. The results of this study were unique in that the association between delayed ANC visits and adequacy of ANC visits were examined using multivariable logistic model and the marginal effects using predicted probabilities. Results revealed that older age interval has higher odds of inadequate ANC visits. More so, type of place of residence was associated with delayed initiation of ANC visits, with rural women having the higher odds of

  20. Quality of antenatal care services and completion of four or more antenatal care visits in Ethiopia: a finding based on a demographic and health survey.

    Science.gov (United States)

    Muchie, Kindie Fentahun

    2017-09-11

    Antenatal care (ANC) is one of the core interventions for improving maternal outcomes. The average annual decline of maternal mortality rate from 1990 to 2013 was 5% in Ethiopia. This figure was below the least expected 5.5% to achieve the targeted 75% by 1990-2015. Moreover, completion of the recommended four or more ANC visits was only 32%. This study was aimed to examine individual, household and community level potential determinants of completing the recommended visits in the country. The 2014 Ethiopian Mini Demographic and Health Survey data were used. Among women aged 15-49 years 3694 who had given birth in the 5 years preceding the survey were included in the analysis. The robust standard error method of generalized estimation equations were used for binary outcome variable from the clustered data. Only 33.0% (95% CI 31. 5% 34.5%) of women completed the recommended visits. Out of the total women, 56.5% had at least one ANC visit. Out of those who had at least one ANC visit, 37.4% visited in their first trimester. Completing the recommended visits was negatively associated with women in the lower educational level, lower economic conditions, higher birth order, and rural residence. But, it was positively associated with the community level high quality ANC services received. Difference in age and region also affected the completion of the recommended visits. The finding revealed the need for improving the uptake of ANC services, early arrival in the first trimester for services, and motivating mothers that begin ANC to confirm continuity. Strategies to foster completing the recommended visits should focus on upgrading quality of care services at the community level. Women in low economic level, high birth order, rural residence, and low educational status should be given special attention. Early and late age groups should be given special attention regarding the services.

  1. Nonurgent Emergency Department Visits by Insured and Uninsured Adults.

    Science.gov (United States)

    Searing, Lisabeth M; Cantlin, Kelly A

    2016-01-01

    To compare nonurgent emergency department (ED) visits by insured and uninsured adults in a Midwest community. Records for this secondary data analysis included 84,877 nonurgent visits to a Midwest ED from September 2004 to January 2012. Insured versus uninsured visits were analyzed using t tests for continuous variables and chi-squared tests for categorical variables. Standardized residuals were compared to determine if changes over time were statistically significant. Variables included demographic characteristics of patients, payment source, patients' access to primary care, acuity rating, time of visit, and the stated reason for the visit. Of all nonurgent visits, 77.9% were made by insured adults. Insured nonurgent visits were more often made by adults who were female, older, White, and had a primary care provider (PCP). Nonurgent visits on weekdays between the hours of 09:00 and 18:00 were more likely to be uninsured visits. Dental issues were the fourth most common issue for uninsured visits. Nonurgent ED visits occur when more appropriate options for prompt care are available in the community. Interventions should target both patients and PCPs. While patients should contact their PCP when in need of prompt care, PCPs should refer patients to facilities other than the ED when medically appropriate. © 2015 Wiley Periodicals, Inc.

  2. Are men shortchanged on health? Perspective on health care utilization and health risk behavior in men and women in the United States.

    Science.gov (United States)

    Pinkhasov, R M; Wong, J; Kashanian, J; Lee, M; Samadi, D B; Pinkhasov, M M; Shabsigh, R

    2010-03-01

    Significant gender disparities exist in life expectancy and major disease morbidity. There is a need to understand the major issues related to men's health that contributes to these significant disparities. It is hypothesized that, high-risk behaviors and low utilization of all and preventive health services contribute to the higher mortality and the higher and earlier morbidity in men. Data was collected from CDC: Health United States, 2007; Health Behavior of Adults: United States 2002-04; and National Ambulatory Medical Care Survey: 2005 Summary. In United States, men are more likely to be regular and heavy alcohol drinkers, heavier smokers who are less likely to quit, non-medical illicit drug users, and are more overweight compared to women. Men are less likely to utilize health care visits to doctor's offices, emergency departments (ED), and physician home visits than women. They are also less likely to make preventive care, hospice care, dental care visits, and have fewer hospital discharges and shorter hospital stays than women. High-risk behaviors and low utilization of health services may contribute to the lower life expectancy in men. In the context of public health, behavioral and preventive interventions are needed to reduce the gender disparity.

  3. Ambulatory Care after Acute Kidney Injury: An Opportunity to Improve Patient Outcomes

    Directory of Open Access Journals (Sweden)

    Samuel A. Silver

    2015-10-01

    Full Text Available Purpose of review: Acute kidney injury (AKI is an increasingly common problem among hospitalized patients. Patients who survive an AKI-associated hospitalization are at higher risk of de novo and worsening chronic kidney disease, end-stage kidney disease, cardiovascular disease, and death. For hospitalized patients with dialysis-requiring AKI, outpatient follow-up with a nephrologist within 90 days of hospital discharge has been associated with enhanced survival. However, most patients who survive an AKI episode do not receive any follow-up nephrology care. This narrative review describes the experience of two new clinical programs to care for AKI patients after hospital discharge: the Acute Kidney Injury Follow-up Clinic for adults (St. Michael's Hospital and University Health Network, Toronto, Canada and the AKI Survivor Clinic for children (Cincinnati Children's Hospital, USA. Sources of information: MEDLINE, PubMed, ISI Web of Science Findings: These two ambulatory clinics have been in existence for close to two (adult and four (pediatric years, and were developed separately and independently in different populations and health systems. The components of both clinics are described, including the target population, referral process, medical interventions, patient education activities, and follow-up schedule. Common elements include targeting patients with KDIGO stage 2 or 3 AKI, regular audits of the inpatient nephrology census to track eligible patients, medication reconciliation, and education on the long-term consequences of AKI. Limitations: Despite the theoretical benefits of post-AKI follow-up and the clinic components described, there is no high quality evidence to prove that the interventions implemented in these clinics will reduce morbidity or mortality. Therefore, we also present a plan to evaluate the adult AKI Follow-up Clinic in order to determine if it can improve clinical outcomes compared to patients with AKI who do not

  4. Work engagement and attitudes toward caring for dying patients and families among home-visiting nurses in Japan.

    Science.gov (United States)

    Mahiro, Sakai; Takashi, Naruse; Satoko, Nagata

    2014-07-01

    Nurses with higher levels of work engagement tend to be highly efficient in their work and more willing to keep working and to provide patient-centred care. However, whether more engaged nurses provide end-of-life care more proactively has not been examined in the home-care setting. This study aimed to examine work engagement among home-visiting nurses in Japan and its relationship with their attitudes toward caring for dying patients and their families. A total of 343 nurses working in 62 agencies across Chiba prefecture, eastern Japan, received an anonymous self-administered questionnaire from July to August 2012. The authors performed multiple regression analysis to explore the relationships between home-visiting nurses' work engagement and attitudes. Data from 184 nurses (53.6%) was analysed. Work engagement was significantly positively related to the nurses' attitudes toward caring for dying patients and their families. As more engaged nurses tend to have more positive attitudes toward caring for dying patients and their families, further research is needed to identify the factors that might help nursing managers to enhance their staff's engagement and perhaps thereby improve their attitudes, with the ultimate aim of achieving better outcomes for patients and families.

  5. Ambulatory oral surgery: 1-year experience with 11 680 patients from Zagreb district, Croatia

    Science.gov (United States)

    Jokić, Dražen; Macan, Darko; Perić, Berislav; Tadić, Marinka; Biočić, Josip; Đanić, Petar; Brajdić, Davor

    2013-01-01

    Aim To examine the types and frequencies of oral surgery diagnoses and ambulatory oral surgical treatments during one year period at the Department of Oral Surgery, University Hospital Dubrava in Zagreb, Croatia. Methods Sociodemographic and clinical data on 11 680 ambulatory patients, treated between January 1 and of December 31, 2011 were retrieved from the hospital database using a specific protocol. The obtained data were subsequently analyzed in order to assess the frequency of diagnoses and differences in sex and age. Results The most common ambulatory procedure was tooth extraction (37.67%) and the most common procedure in ambulatory operating room was alveolectomy (57.25%). The test of proportions showed that significantly more extractions (P Zagreb than in patients residing in rural areas. Conclusion The data from this study may be useful for planning of ambulatory oral surgery services, budgeting, and sustaining quality improvement, enhancing oral surgical curricula, training and education of primary health care doctors and oral surgery specialists, and promoting patients’ awareness of the importance of oral health. PMID:23444246

  6. First-Year Analysis of a New, Home-Based Palliative Care Program Offered Jointly by a Community Hospital and Local Visiting Nurse Service.

    Science.gov (United States)

    Pouliot, Katherine; Weisse, Carol S; Pratt, David S; DiSorbo, Philip

    2017-03-01

    There is a growing need for home-based palliative care services, especially for seriously ill individuals who want to avoid hospitalizations and remain with their regular outside care providers. To evaluate the effectiveness of Care Choices, a new in-home palliative care program provided by the Visiting Nurse Services of Northeastern New York and Ellis Medicine's community hospital serving New York's Capital District. This prospective cohort study assessed patient outcomes over the course of 1 year for 123 patients (49 men and 74 women) with serious illnesses who were new enrollees in the program. Quality of life was assessed at baseline and after 1 month on service. Satisfaction with care was measured after 1 and 3 months on service. The number of emergency department visits and inpatient hospitalizations pre- and postenrollment was measured for all enrollees. Patients were highly satisfied (72.7%-100%) with their initial care and reported greater satisfaction ( P care service. An in-home palliative care program offered jointly through a visiting nurse service and community hospital may be a successful model for providing quality care that satisfies chronically ill patients' desire to remain at home and avoid hospital admissions.

  7. Cost-effectiveness analysis of computerized ECG interpretation system in an ambulatory health care organization.

    Science.gov (United States)

    Carel, R S

    1982-04-01

    The cost-effectiveness of a computerized ECG interpretation system in an ambulatory health care organization has been evaluated in comparison with a conventional (manual) system. The automated system was shown to be more cost-effective at a minimum load of 2,500 patients/month. At larger monthly loads an even greater cost-effectiveness was found, the average cost/ECG being about $2. In the manual system the cost/unit is practically independent of patient load. This is primarily due to the fact that 87% of the cost/ECG is attributable to wages and fees of highly trained personnel. In the automated system, on the other hand, the cost/ECG is heavily dependent on examinee load. This is due to the relatively large impact of equipment depreciation on fixed (and total) cost. Utilization of a computer-assisted system leads to marked reduction in cardiologists' interpretation time, substantially shorter turnaround time (of unconfirmed reports), and potential provision of simultaneous service at several remotely located "heart stations."

  8. The effectiveness of group visits for patients with heart failure on knowledge, quality of life, self-care, and readmissions: a systematic review protocol.

    Science.gov (United States)

    Slyer, Jason T; Ferrara, Lucille R

    The objective of this review is to identify the effectiveness of group visits for patients with heart failure (HF) on knowledge, quality of life, self-care behaviors, and hospital readmissions. BACKGROUND: Heart failure (HF) continues to be a major health burden throughout the world. There are currently over 5.7 million Americans, 15 million Europeans, and 277,800 Australians living with HF. These numbers are expected to double by 2040. Patients and caregivers perform the majority of HF care in the home. Patients with HF need to learn to be successful in self-managing their condition to lessen the burden of symptoms such as fatigue, dyspnea, and edema.Patient education is the primary process used to increase knowledge of self-care practices for patients with HF. Patients with HF need to follow a complex medical regimen while adhering to a low sodium diet and prescribed fluid restrictions. In addition patients monitor their physical condition daily for exacerbation of symptoms or signs of fluid overload. Education, behavior modification, and skill development are necessary for a patient with HF to be successful in self-managing their condition.Most HF education occurs during one-on-one visits between the patient and the health care provider in an examination room during a regular clinic visit. However, there is usually limited time to address all of the needed education topics in an in-depth, meaningful manner with information the patient can take home and utilize in their daily routines.Group visits provide an alternative venue to provide care for this complex patient population. A group visit is an interactive process between a health care provider and a small group of patients and their caregivers who usually share a common medical concern. The participants of group visits can benefit from the knowledge and experiences of the other participants while providing support and encouragement to each other as they learn to cope with living with a chronic condition

  9. Characteristics of communication with older people in home care: A qualitative analysis of audio recordings of home care visits.

    Science.gov (United States)

    Kristensen, Dorte V; Sundler, Annelie J; Eide, Hilde; Hafskjold, Linda; Ruud, Iren; Holmström, Inger K

    2017-12-01

    To describe the characteristics of communication practice in home care visits between older people (over 65 years old) and nurse assistants and to discuss the findings from a person-centered perspective. The older population is increasing worldwide, along with the need for healthcare services in the person's home. To achieve a high-quality care, person-centered communication is crucial. A descriptive design with a qualitative inductive approach was used. Fifteen audio recordings of naturally occurring conversations between 12 nurse assistants and 13 older people in Norway were analysed by qualitative content analysis. Four categories were revealed through analysis: (i) supporting older people's connection to everyday life; (ii) supporting older people's involvement in their own care; (iii) attention to older people's bodily and existential needs; and (iv) the impact of continuity and predictability on older people's well-being. The communication between the older people and the nurse assistants during home care visits was mainly task-oriented, but also related to the person. The older people were involved in the tasks to be carried out and humour was part of the communication. Greater attention was paid to bodily than existential needs. The communication was connected with the older people's everyday life in several ways. Time frames and interruptions concern the older people; hearing and speech impairments were a challenge to communication. To enhance person-centred communication, further studies are needed, especially intervention studies for healthcare professionals and students. Being responsive to older people's subjective experiences is important in meeting their needs in home care. Communication that addresses the need for trust and predictability is important for older people. Responding to existential needs require more attention. The home care setting has an impact on communication. © 2017 John Wiley & Sons Ltd.

  10. Prediction of Unmet Primary Care Needs for the Medically Vulnerable Post-Disaster: An Interrupted Time-Series Analysis of Health System Responses

    Directory of Open Access Journals (Sweden)

    Amy B. Martin

    2012-09-01

    Full Text Available Disasters serve as shocks and precipitate unanticipated disturbances to the health care system. Public health surveillance is generally focused on monitoring latent health and environmental exposure effects, rather than health system performance in response to these local shocks. The following intervention study sought to determine the long-term effects of the 2005 chlorine spill in Graniteville, South Carolina on primary care access for vulnerable populations. We used an interrupted time-series approach to model monthly visits for Ambulatory Care Sensitive Conditions, an indicator of unmet primary care need, to quantify the impact of the disaster on unmet primary care need in Medicaid beneficiaries. The results showed Medicaid beneficiaries in the directly impacted service area experienced improved access to primary care in the 24 months post-disaster. We provide evidence that a health system serving the medically underserved can prove resilient and display improved adaptive capacity under adverse circumstances (i.e., technological disasters to ensure access to primary care for vulnerable sub-groups. The results suggests a new application for ambulatory care sensitive conditions as a population-based metric to advance anecdotal evidence of secondary surge and evaluate pre- and post-health system surge capacity following a disaster.

  11. Injectable loop recorder implantation in an ambulatory setting by advanced practice providers: Analysis of outcomes.

    Science.gov (United States)

    Kipp, Ryan; Young, Natasha; Barnett, Anne; Kopp, Douglas; Leal, Miguel A; Eckhardt, Lee L; Teelin, Thomas; Hoffmayer, Kurt S; Wright, Jennifer; Field, Michael

    2017-09-01

    Implantable loop recorder (ILR) insertion has historically been performed in a surgical environment such as the electrophysiology (EP) lab. The newest generation loop recorder (Medtronic Reveal LINQ™, Minneapolis, MN, USA) is injectable with potential for implantation in a non-EP lab setting by advanced practice providers (APPs) facilitating improved workflow and resource utilization. We report the safety and efficacy of injectable ILR placement in the ambulatory care setting by APPs. A retrospective review was performed including all patients referred for injectable ILR placement from March 2014 to November 2015. All device placement procedures were performed in an ambulatory care setting using the standard manufacturer deployment kit with sterile technique and local anesthetic following a single dose of intravenous antibiotics. Acute procedural success and complication rates following injectable ILR placement in the ambulatory setting were reviewed. During the study period, 125 injectable ILRs were implanted. Acute procedural success with adequate sensing (R-waves ≥ 0.2 mV) occurred in 100% of patients. There were no acute procedural complications. Subacute complications occurred in two patients (1.6% of implantations), including one possible infection treated with oral antibiotics and one device removal due to pain at the implant site. In this retrospective single-center study, implantation of injectable ILR in an ambulatory care setting by APPs following a single dose of intravenous antibiotics and standard manufacturer technique yielded a low complication rate with high acute procedural success. Use of this implantation strategy may improve EP lab workflow while providing a safe and effective technique for device placement. © 2017 Wiley Periodicals, Inc.

  12. The Influence of Ambulatory Aid on Lower-Extremity Muscle Activation During Gait.

    Science.gov (United States)

    Sanders, Michael; Bowden, Anton E; Baker, Spencer; Jensen, Ryan; Nichols, McKenzie; Seeley, Matthew K

    2018-05-10

    Foot and ankle injuries are common and often require a nonweight-bearing period of immobilization for the involved leg. This nonweight-bearing period usually results in muscle atrophy for the involved leg. There is a dearth of objective data describing muscle activation for different ambulatory aids that are used during the aforementioned nonweight-bearing period. To compare activation amplitudes for 4 leg muscles during (1) able-bodied gait and (2) ambulation involving 3 different ambulatory aids that can be used during the acute phase of foot and ankle injury care. Within-subject, repeated measures. University biomechanics laboratory. Sixteen able-bodied individuals (7 females and 9 males). Each participant performed able-bodied gait and ambulation using 3 different ambulatory aids (traditional axillary crutches, knee scooter, and a novel lower-leg prosthesis). Muscle activation amplitude quantified via mean surface electromyography amplitude throughout the stance phase of ambulation. Numerous statistical differences (P < .05) existed for muscle activation amplitude between the 4 observed muscles, 3 ambulatory aids, and able-bodied gait. For the involved leg, comparing the 3 ambulatory aids: (1) knee scooter ambulation resulted in the greatest vastus lateralis activation, (2) ambulation using the novel prosthesis and traditional crutches resulted in greater biceps femoris activation than knee scooter ambulation, and (3) ambulation using the novel prosthesis resulted in the greatest gastrocnemius activation (P < .05). Generally speaking, muscle activation amplitudes were most similar to able-bodied gait when subjects were ambulating using the knee scooter or novel prosthesis. Type of ambulatory aid influences muscle activation amplitude. Traditional axillary crutches appear to be less likely to mitigate muscle atrophy during the nonweighting, immobilization period that often follows foot or ankle injuries. Researchers and clinicians should consider

  13. Reducing High-Users' Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study.

    Science.gov (United States)

    Tsai, Meng-Han; Xirasagar, Sudha; Carroll, Scott; Bryan, Charles S; Gallagher, Pamela J; Davis, Kim; Jauch, Edward C

    2018-01-01

    Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use-based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users' mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users' rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention.

  14. Reducing High-Users’ Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study

    Science.gov (United States)

    Tsai, Meng-Han; Xirasagar, Sudha; Carroll, Scott; Bryan, Charles S.; Gallagher, Pamela J.; Davis, Kim; Jauch, Edward C.

    2018-01-01

    Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use–based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users’ mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users’ rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention. PMID:29591539

  15. Diabetes treatment satisfaction, medication adherence, and glycemic control among ambulatory type 2 diabetic nigerians in a primary care clinic of a tertiary hospital situated in a resource-limited environment of Southeast Nigeria

    Directory of Open Access Journals (Sweden)

    Iloh Gabriel Uche Pascal

    2016-01-01

    Full Text Available Background: Diabetic treatment satisfaction, medication adherence, and glycemic control are widely recognized as the cornerstones for successful management of diabetes and proxy indicators of quality of care. However, in Nigeria, nothing is known on the role of diabetic treatment satisfaction on medication adherence and blood glucose control. Aim: The study was aimed at determining the role of diabetes treatment satisfaction in medication adherence and glycemic control among ambulatory type 2 diabetic Nigerians in a primary care clinic in Southeast Nigeria. Materials and Methods: This was a descriptive study that was carried out on 120 type 2 diabetic Nigerians who were on treatment for at least 3 months at the primary care clinic of a tertiary hospital in Nigeria. Diabetes treatment satisfaction and medication adherence were assessed in the previous 30 days using pretested, interviewer-administered questionnaire on self-reported satisfaction and adherence to therapy, respectively. Glycemic control was assessed in the previous 1 month. A patient was defined to have goal glycemic control if the fasting blood glucose at the end of the study, visit was between 70 and 130 mg/dL. Results: Diabetic treatment satisfaction, medication adherence, and glycemic control rates were 85.8%, 72.5%, and 61.7%, respectively. Diabetic treatment satisfaction was significantly associated with medication adherence (P = 0.025 and glycemic control (P = 0.04. Conclusion: Diabetic treatment satisfaction was significantly associated with medication adherence and glycemic control. However, treatment satisfaction did not translate marginally to higher medication and glycemic control. Diabetic treatment satisfaction should be integrated into a standard care package for diabetic patients in primary care settings.

  16. ORAL HEALTH TO PATIENTS WITH ESPECIAL NEEDS: DOMICILIARY VISIT AS A HEALTH CARE STRATEGY

    Directory of Open Access Journals (Sweden)

    Giselle Boaventura Barros

    2006-12-01

    Full Text Available This work relates an experience that uses the domiciliary visit as strategy to extend the oral health care, offering access to people with psychological and motor difficulties. The domiciliary visit consists in a set of health actions that promotes both educative and curative assistance. The present work was developed in the area of Lírio dos Vales Health Unit in Alagoinhas BA. The aim of the activities was to promote health through the motivation and education actions, preventing illnesses, as well as the clinical treatment to the attended individuals. During the domiciliary visits the following procedures had been carried through: recognition of individual and family life conditions, medical history, clinical examination, screening for oral injuries, topical application of fluoride, dental extraction in units with periodontal illness and remaining dental roots; beyond health education and supervised brushing sessions. As results, in six months of activities were realized: 54 domiciliary visits, 34 supervised brushing sessions, 27 fluoride applications and 23 dental extractions. It can be concluded that domiciliary visit, in the context of the PSF, brings positive results for oral health promotion to a parcel of the population that would not have access to the traditional Dentistry, particularly to bedridden patients or to those patients with psychomotor difficulty. Besides this, it allows the oral injuries diagnose anticipation, attendance personalization and humanization and a better relationship between professional and user.

  17. Oral and Topical Antibiotics for Clinically Infected Eczema in Children: A Pragmatic Randomized Controlled Trial in Ambulatory Care.

    Science.gov (United States)

    Francis, Nick A; Ridd, Matthew J; Thomas-Jones, Emma; Butler, Christopher C; Hood, Kerenza; Shepherd, Victoria; Marwick, Charis A; Huang, Chao; Longo, Mirella; Wootton, Mandy; Sullivan, Frank

    2017-03-01

    Eczema may flare because of bacterial infection, but evidence supporting antibiotic treatment is of low quality. We aimed to determine the effect of oral and topical antibiotics in addition to topical emollient and corticosteroids in children with clinically infected eczema. We employed a 3-arm, blinded, randomized controlled trial in UK ambulatory care. Children with clinical, non-severely infected eczema were randomized to receive oral and topical placebos (control), oral antibiotic (flucloxacillin) and topical placebo, or topical antibiotic (fusidic acid) and oral placebo, for 1 week. We compared Patient Oriented Eczema Measure (POEM) scores at 2 weeks using analysis of covariance (ANCOVA). We randomized 113 children (40 to control, 36 to oral antibiotic, and 37 to topical antibiotic). Mean (SD) baseline Patient Oriented Eczema Measure scores were 13.4 (5.1) for the control group, 14.6 (5.3) for the oral antibiotic group, and 16.9 (5.5) for the topical antibiotic group. At baseline, 104 children (93%) had 1 or more of the following findings: weeping, crusting, pustules, or painful skin. Mean (SD) POEM scores at 2 weeks were 6.2 (6.0) for control, 8.3 (7.3) for the oral antibiotic group, and 9.3 (6.2) for the topical antibiotic group. Controlling for baseline POEM score, neither oral nor topical antibiotics produced a significant difference in mean (95% CI) POEM scores (1.5 [-1.4 to 4.4] and 1.5 [-1.6 to 4.5] respectively). There were no significant differences in adverse effects and no serious adverse events. We found rapid resolution in response to topical steroid and emollient treatment and ruled out a clinically meaningful benefit from the addition of either oral or topical antibiotics. Children seen in ambulatory care with mild clinically infected eczema do not need treatment with antibiotics. © 2017 Annals of Family Medicine, Inc.

  18. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care

    DEFF Research Database (Denmark)

    Thomsen, Linda Aagaard; Winterstein, Almut G; Søndergaard, Birthe

    2007-01-01

    studies, health services research, and follow-up studies. Additional articles were found in the reference sections of retrieved articles. STUDY SELECTION AND DATA EXTRACTION: Peer-reviewed articles assessing pADEs in ambulatory care, with detailed descriptions/frequency distributions of (1) ADE....../pADE incidence, (2) clinical outcomes, (3) associated drug groups, and/or (4) underlying medication errors were included. Study country, year and design, sample size, follow-up time, ADE/pADE identification method, proportion of ADEs/pADEs and ADEs/pADEs requiring hospital admission, and frequency distribution......-months, and the pADE incidence was 5.6 per 1000 person-months (1.1-10.1). The median ADE preventability rate was 21% (11-38%). The median incidence of ADEs requiring hospital admission was 0.45 (0.10-13.1) per 1000 person-months, and the median incidence of pADEs requiring hospital admission was 4.5 per 1000 person...

  19. Identifying Natural Alignments Between Ambulatory Surgery Centers and Local Health Systems: Building Broader Communities of Surgical Care.

    Science.gov (United States)

    Funk, Russell J; Owen-Smith, Jason; Landon, Bruce E; Birkmeyer, John D; Hollingsworth, John M

    2017-02-01

    To develop and compare methods for identifying natural alignments between ambulatory surgery centers (ASCs) and hospitals that anchor local health systems. Using all-payer data from Florida's State Ambulatory Surgery and Inpatient Databases (2005-2009), we developed 3 methods for identifying alignments between ASCS and hospitals. The first, a geographic proximity approach, used spatial data to assign an ASC to its nearest hospital neighbor. The second, a predominant affiliation approach, assigned an ASC to the hospital with which it shared a plurality of surgeons. The third, a network community approach, linked an ASC with a larger group of hospitals held together by naturally occurring physician networks. We compared each method in terms of its ability to capture meaningful and stable affiliations and its administrative simplicity. Although the proximity approach was simplest to implement and produced the most durable alignments, ASC surgeon's loyalty to the assigned hospital was low with this method. The predominant affiliation and network community approaches performed better and nearly equivalently on these metrics, capturing more meaningful affiliations between ASCs and hospitals. However, the latter's alignments were least durable, and it was complex to administer. We describe 3 methods for identifying natural alignments between ASCs and hospitals, each with strengths and weaknesses. These methods will help health system managers identify ASCs with which to partner. Moreover, health services researchers and policy analysts can use them to study broader communities of surgical care.

  20. Factors associated with pneumonia in Yanomami children hospitalized for Ambulatory Care sensitive conditions in the north of Brazil.

    Science.gov (United States)

    Caldart, Raquel Voges; Marrero, Lihsieh; Basta, Paulo Cesar; Orellana, Jesem Douglas Yamall

    2016-05-01

    In developing countries, pneumonia is the leading cause of sickness and mortality in childhood, especially among vulnerable groups. The scope of this study was to analyze the factors associated with pneumonia in Yanomami children hospitalized for Ambulatory Care Sensitive Conditions (ACSC). Hospital admissions were divided into two groups: i) pneumonia; and ii) other causes, according to the Brazilian ACSC list. Adjusted hospitalization rates were estimated and unconditional logistic regression was used to analyze factors associated with pneumonia. Over 90% of the registered cases were considered ACSC. The adjusted rate of ACSC was 18.6/1000. The odds ratio of hospitalization for pneumonia was 2.7 (CI: 1.3-5.4) times higher in children aged between 0.1 and 5.9 months; 1.9 (CI: 1.1-3.3) times higher in children who were hospitalized for 8-14 days; and three (CI: 1.2-7.5) times higher in children with a secondary diagnosis of malnutrition. The excess of avoidable hospitalizations is a clear indication of the low quality of care and limited accessibility to primary health care in indigenous territories, which is contrary to the assistance model proposed by the indigenous healthcare subsystem in Brazil, which should in theory focus on welfare technologies based on primary health care.

  1. Informed and patient-centered decision-making in the primary care visits of African Americans with depression.

    Science.gov (United States)

    Hines, Anika L; Roter, Debra; Ghods Dinoso, Bri K; Carson, Kathryn A; Daumit, Gail L; Cooper, Lisa A

    2018-02-01

    We examined the prevalence and extent of informed decision-making (IDM) and patient-centered decision-making (PCDM) in primary care visits of African Americans with depression. We performed a cross-sectional analysis of audiotaped clinical encounters and post-visit surveys of 76 patients and their clinicians. We used RIAS to characterize patient-centeredness of visit dialogue. IDM entailed discussion of 3 components: the nature of the decision, alternatives, and pros/cons. PCDM entailed discussion of: lifestyle/coping strategies, knowledge/beliefs, or treatment concerns. We examined the association of IDM and PCDM with visit duration, overall patient-centeredness, and patient/clinician interpersonal ratings. Approximately one-quarter of medication and counseling decisions included essential IDM elements and 40% included at least one PCDM element. In high patient-centered visits, IDM was associated with patients feeling respected in counseling and liking clinicians in medication decisions. IDM was not related to clinician ratings. In low patient-centered visits, PCDM in counseling decisions was positively associated with patients feeling respected and clinicians respecting patients. The associations between IDM and PCDM with interpersonal ratings was moderated by overall patient-centeredness of the visit, which may be indicative of broader cross-cultural communication issues. Strengthening partnerships between depressed African Americans and their clinicians may improve patient-engaged decision-making. Copyright © 2017 Elsevier B.V. All rights reserved.

  2. Participation restrictions in ambulatory amyotrophic lateral sclerosis patients: Physical and psychological factors.

    Science.gov (United States)

    Van Groenestijn, Annerieke C; Schröder, Carin D; Kruitwagen-Van Reenen, Esther T; Van Den Berg, Leonard H; Visser-Meily, Johanna M A

    2017-11-01

    The aim of this study was to assess the prevalence of participation restrictions in ambulatory patients with amyotrophic lateral sclerosis (ALS) and to identify physical and psychological contributory factors. In this cross-sectional study, self-reported participation restrictions of 72 ambulatory ALS patients were assessed using the social health status dimension (SIPSOC) of the Sickness Impact Profile (SIP-68). Associations between SIPSOC and physical functioning, psychological factors, and demographic factors were analyzed using hierarchical regression analyses. Ninety-two percent of the patients reported participation restrictions; 54.9% could be explained by physical functioning; psychological factors accounted for 8.1% of the variance. Lung capacity, functional mobility, fatigue, and helplessness were independently associated with participation restrictions. Ambulatory ALS patients have participation restrictions, which may be influenced if early ALS care is directed toward lung capacity, functional mobility, fatigue, and feelings of helplessness. Muscle Nerve 56: 912-918, 2017. © 2017 Wiley Periodicals, Inc.

  3. Enhanced interdisciplinary care improves self-care ability and decreases emergency department visits for older Taiwanese patients over 2 years after hip-fracture surgery: A randomised controlled trial.

    Science.gov (United States)

    Shyu, Yea-Ing L; Liang, Jersey; Tseng, Ming-Yueh; Li, Hsiao-Juan; Wu, Chi-Chuan; Cheng, Huey-Shinn; Chou, Shih-Wei; Chen, Ching-Yen; Yang, Ching-Tzu

    2016-04-01

    Little evidence is available on the longer-term effects (beyond 12 months) of intervention models consisting of hip fracture-specific care in conjunction with management of malnutrition, depression, and falls. To compare the relative effects of an interdisciplinary care, and a comprehensive care programme with those of usual care for elderly patients with a hip fracture on self-care ability, health care use, and mortality. Randomised experimental trial. A 3000-bed medical centre in northern Taiwan. Patients with hip fracture aged 60 years or older (N=299). Patients were randomly assigned to three groups: comprehensive care (n=99), interdisciplinary care (n=101), and usual care (control) (n=99). Usual care entailed only one or two in-hospital rehabilitation sessions. Interdisciplinary care included not only hospital rehabilitation, but also geriatric consultation, discharge planning, and 4-month in-home rehabilitation. Building upon interdisciplinary care, comprehensive care extended in-home rehabilitation to 12 months and added management of malnutrition and depressive symptoms, and fall prevention. Patients' self-care ability was measured by activities of daily living and instrumental activities of daily living using the Chinese Barthel Index and Chinese version Instrumental Activities of Daily Living scale, respectively. Outcomes were assessed before discharge, and 1, 3, 6, 12, 18, 24 months following hip fracture. Hierarchical linear models were used to analyse health outcomes and health care utilisation, including emergency department visit and hospital re-admission. The comprehensive care group had better performance trajectories for both measures of activities of daily living and fewer emergency department visits than the usual care group, but no difference in hospital readmissions. The interdisciplinary care and usual care groups did not differ in trajectories of self-care ability and service utilisation. The three groups did not differ in mortality during

  4. Patients' quality assessment of ambulatory obstetric and gynaecological services.

    Science.gov (United States)

    Bojar, I; Wdowiak, L; Ostrowski, T

    2005-01-01

    The quality could be assessed from two perspectives: internal and external. From the internal perspective the quality means being consistent with particular conditions and standards. The external perspective is based on relative assessment of the product made by a client who is also aware of other competitors' offer. Despite the professional assessment which is focused on providing health services according to medical and managerial correctness, patient's assessment is also relevant. Measuring patient's satisfaction is additional method of health services quality assessment. The aim of the study was to estimate patients' opinion on quality of ambulatory obstetric and gynaecological services. The study was conducted in 11 obstetric and gynaecological out-patient clinics of Lublin in September and October 2003. The study tool was an author's questionnaire. Patients were asked to assess such areas as registration before visit, their relationship with nurses and gynaecologists and other aspects of services provision like intimacy assurance and respecting Patient's Rights. The collected data was statistically analysed. 635 patients took part in the study. The biggest groups in the studied population were women at the age of 20-30 years, married, living in cities and secondary educated. It was found that around half of the population is satisfied and 2.2% of them are unsatisfied with the fact that they have chosen particular out-patient clinic. More than 70% of women had positive opinion of following aspects influencing general opinion about service quality: politness of reception desk staff, opening hours, the length of time before a patient is seen by the specialist, intimacy assurance and respect for Patient's Rights in the practice. 80% of patients were satisfied with the relationship with nurses and 3.3% were unsatisfied with it. Eight patients out of ten were satisfied with gynaecological care, less than 2% were unsatisfied. The studied women had also high opinion

  5. A low-cost ultrasound program leads to increased antenatal clinic visits and attended deliveries at a health care clinic in rural Uganda.

    Directory of Open Access Journals (Sweden)

    Andrew B Ross

    Full Text Available BACKGROUND: In June of 2010, an antenatal ultrasound program to perform basic screening for high-risk pregnancies was introduced at a community health care center in rural Uganda. Whether the addition of ultrasound scanning to antenatal visits at the health center would encourage or discourage potential patients was unknown. Our study sought to evaluate trends in the numbers of antenatal visits and deliveries at the clinic, pre- and post-introduction of antenatal ultrasound to determine what effect the presence of ultrasound at the clinic had on these metrics. METHODS AND FINDINGS: Records at Nawanyago clinic were reviewed to obtain the number of antenatal visits and deliveries for the 42 months preceding the introduction of ultrasound and the 23 months following. The monthly mean deliveries and antenatal visits by category (first visit through fourth return visit were compared pre- and post- ultrasound using a Kruskal-Wallis one-way ANOVA. Following the introduction of ultrasound, significant increases were seen in the number of mean monthly deliveries and antenatal visits. The mean number of monthly deliveries at the clinic increased by 17.0 (13.3-20.6, 95% CI from a pre-ultrasound average of 28.4 to a post-ultrasound monthly average of 45.4. The number of deliveries at a comparison clinic remained flat over this same time period. The monthly mean number of antenatal visits increased by 97.4 (83.3-111.5, 95% CI from a baseline monthly average of 133.5 to a post-ultrasound monthly mean of 231.0, with increases seen in all categories of antenatal visits. CONCLUSIONS: The availability of a low-cost antenatal ultrasound program may assist progress towards Millennium Development Goal 5 by encouraging women in a rural environment to come to a health care facility for skilled antenatal care and delivery assistance instead of utilizing more traditional methods.

  6. Study protocol to assess the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units: a cluster-randomised, crossover trial (The ICU Visits Study).

    Science.gov (United States)

    Rosa, Regis Goulart; Falavigna, Maicon; Robinson, Caroline Cabral; da Silva, Daiana Barbosa; Kochhann, Renata; de Moura, Rafaela Moraes; Santos, Mariana Martins Siqueira; Sganzerla, Daniel; Giordani, Natalia Elis; Eugênio, Cláudia; Ribeiro, Tarissa; Cavalcanti, Alexandre Biasi; Bozza, Fernando; Azevedo, Luciano Cesar Pontes; Machado, Flávia Ribeiro; Salluh, Jorge Ibrain Figueira; Pellegrini, José Augusto Santos; Moraes, Rafael Barberena; Hochegger, Taís; Amaral, Alexandre; Teles, José Mario Meira; da Luz, Lucas Gobetti; Barbosa, Mirceli Goulart; Birriel, Daniella Cunha; Ferraz, Iris de Lima; Nobre, Vandack; Valentim, Helen Martins; Corrêa E Castro, Livia; Duarte, Péricles Almeida Delfino; Tregnago, Rogério; Barilli, Sofia Louise Santin; Brandão, Nilton; Giannini, Alberto; Teixeira, Cassiano

    2018-04-13

    Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals. A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals. The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through

  7. "Let him speak:" a descriptive qualitative study of the roles and behaviors of family companions in primary care visits among older adults with cognitive impairment.

    Science.gov (United States)

    Vick, Judith B; Amjad, Halima; Smith, Katherine C; Boyd, Cynthia M; Gitlin, Laura N; Roth, David L; Roter, Debra L; Wolff, Jennifer L

    2018-01-01

    Cognitive impairment poses communication challenges in primary care. Although family "companions" commonly attend primary care visits of older adults with cognitive impairment, little is known about how their involvement affects communication. Therefore, we sought to understand how companion involvement affects the quality of primary care visit communication for older adults with cognitive impairment. Cross-sectional, descriptive qualitative study participants were as follows: (1) English-speaking adults age 65 or older with mild, moderate, or severe cognitive impairment; (2) family members or other unpaid companions who accompany older adults to primary care visits; and (3) primary care clinicians. Twenty semi-structured and in-depth qualitative interviews of older adults and their companions (N = 20 dyads) and two focus groups (N = 10 primary care clinicians) were conducted. Interviews and focus groups were transcribed and analyzed thematically. Family companions commonly facilitate communication by advocating for patients, ensuring the accuracy of information exchange and understanding, and preserving rapport. Significant communication challenges were also identified, including patient and companion role ambiguity, competing visit agendas, and primary care clinician confusion regarding the most accurate source of information. Patients, companions, and clinicians each identified strategies to improve communication, chief among them being to identify, differentiate, and respect both patient and companion priorities and perspectives. Family companions actively participate in primary care visits of older adults with cognitive impairment in ways that promote and inhibit effective communication. Findings suggest the need for strategies that more effectively and purposefully involve family in the care of primary care patients with cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

  8. Ambulatory blood pressure and adherence monitoring: diagnosing pseudoresistant hypertension.

    Science.gov (United States)

    Burnier, Michel; Wuerzner, Gregoire

    2014-01-01

    A small proportion of the treated hypertensive population consistently has a blood pressure greater than 140/90 mm Hg despite a triple therapy including a diuretic, a calcium channel blocker, and a blocker of the renin-angiotensin system. According to guidelines, these patients have so-called resistant hypertension. The prevalence of this clinical condition is higher in tertiary than primary care centers and often is associated with chronic kidney disease, diabetes, obesity, and sleep apnea syndrome. Exclusion of pseudoresistant hypertension using ambulatory or home blood pressure monitoring is a crucial step in the investigation of patients with resistant hypertension. Thus, among the multiple factors to consider when investigating patients with resistant hypertension, ambulatory blood pressure monitoring should be performed very early. Among other factors to consider, physicians should investigate patient adherence to therapy, assess the adequacy of treatment, exclude interfering factors, and, finally, look for secondary forms of hypertension. Poor adherence to therapy accounts for 30% to 50% of cases of resistance to therapy depending on the methodology used to diagnose adherence problems. This review discusses the clinical factors implicated in the pathogenesis of resistant hypertension with a particular emphasis on pseudoresistance, drug adherence, and the use of ambulatory blood pressure monitoring for the diagnosis and management of resistant hypertension.

  9. Patterns and Predictors of Depression Treatment among Older Adults with Parkinson’s Disease and Depression in Ambulatory Care Settings in the United States

    OpenAIRE

    Bhattacharjee, Sandipan; Vadiei, Nina; Goldstone, Lisa; Alrabiah, Ziyad; Sherman, Scott J.

    2018-01-01

    Little is known regarding depression treatment patterns and predictors among older adults with comorbid Parkinson's disease and depression (dPD) in the United States (US). The objective of this study was to assess the patterns and predictors of depression treatment among older adults with dPD in the US. We adopted a cross-sectional study design by pooling multiple-year data (2005–2011) from the National Ambulatory Medical Care Survey (NAMCS) and the outpatient department of the National Hospi...

  10. HIV care visits and time to viral suppression, 19 U.S. jurisdictions, and implications for treatment, prevention and the national HIV/AIDS strategy.

    Directory of Open Access Journals (Sweden)

    H Irene Hall

    Full Text Available OBJECTIVE: Early and regular care and treatment for human immunodeficiency virus (HIV infection are associated with viral suppression, reductions in transmission risk and improved health outcomes for persons with HIV. We determined, on a population level, the association of care visits with time from HIV diagnosis to viral suppression. METHODS: Using data from 19 areas reporting HIV-related tests to national HIV surveillance, we determined time from diagnosis to viral suppression among 17,028 persons diagnosed with HIV during 2009, followed through December 2011, using data reported through December 2012. Using Cox proportional hazards models, we assessed factors associated with viral suppression, including linkage to care within 3 months of diagnosis, a goal set forth by the National HIV/AIDS Strategy, and number of HIV care visits as determined by CD4 and viral load test results, while controlling for demographic, clinical, and risk characteristics. RESULTS: Of 17,028 persons diagnosed with HIV during 2009 in the 19 areas, 76.6% were linked to care within 3 months of diagnosis and 57.0% had a suppressed viral load during the observation period. Median time from diagnosis to viral suppression was 19 months overall, and 8 months among persons with an initial CD4 count ≤ 350 cells/µL. During the first 12 months after diagnosis, persons linked to care within 3 months experienced shorter times to viral suppression (higher rate of viral suppression per unit time, hazard ratio [HR] = 4.84 versus not linked within 3 months; 95% confidence interval [CI] 4.27, 5.48. Persons with a higher number of time-updated care visits also experienced a shorter time to viral suppression (HR = 1.51 per additional visit, 95% CI 1.49, 1.52. CONCLUSIONS: Timely linkage to care and greater frequency of care visits were associated with faster time to viral suppression with implications for individual health outcomes and for secondary prevention.

  11. Child-Visiting and Domestic Abuse.

    Science.gov (United States)

    Shepard, Melanie

    1992-01-01

    Explains problems with child visiting in cases of domestic abuse. Data on domestic abuse, child care concerns, and child adjustment problems were collected from 25 mothers and 22 fathers at a child visiting program serving separated and abusive families. Psychological abuse of mothers correlated with child adjustment problems. (BB)

  12. Modifying effect of age on the association between ambient ozone and nighttime primary care visits due to asthma attack.

    Science.gov (United States)

    Yamazaki, Shin; Shima, Masayuki; Ando, Michiko; Nitta, Hiroshi

    2009-01-01

    We examined the association between short-term exposure to outdoor air pollution and nighttime primary care visits due to asthma attack. We also investigated the modifying effects of age on this association. A case-crossover study was conducted at a primary care clinic in metropolitan Tokyo. The subjects were 308 children aged 0-14 years and 95 adolescents and adults aged 15-64 years. All subjects made visits to the clinic for an asthma attack at between 7 PM and 12 AM. Data on hourly concentrations of particulate matter with a 50% cut-off aerodynamic diameter asthma attack in warmer months; the association was greater among preschool children.

  13. Ambulatory thyroidectomy: A multistate study of revisits and complications

    OpenAIRE

    Orosco, RK; Lin, HW; Bhattacharyya, N

    2015-01-01

    © 2015 American Academy of Otolaryngology - Head and Neck Surgery Foundation. Objective. Determine rates and reasons for revisits after ambulatory adult thyroidectomy. Study Design. Cross-sectional analysis of multistate ambulatory surgery and hospital databases. Setting. Ambulatory surgery data from the State Ambulatory Surgery Databases of California, Florida, Iowa, and New York for calendar years 2010 and 2011. Subjects and Methods. Ambulatory thyroidectomy cases were linked to state ambul...

  14. External causes of pediatric injury-related emergency department visits in the United States.

    Science.gov (United States)

    Simon, Tamara D; Bublitz, Caroline; Hambidge, Simon J

    2004-10-01

    To characterize the types and external causes of pediatric injury-related visits (IRVs) to emergency departments (EDs), in particular, sports-related injuries. To compare the characteristics of children with IRVs with those with non-IRVs, specifically, differences in IRV rates by race and ethnicity and by health insurance. This was a stratified random-sample survey of EDs in the National Hospital Ambulatory Medical Care Survey (NHAMCS), including all IRVs for patients less than 19 years of age in 1998 (n = 2,656). National estimates of pediatric IRVs were obtained using the assigned patient visit weights in the NHAMCS databases and SUDAAN analyses. Measures of association between predictor variables (patient and health insurance characteristics) and whether a child had an IRV were calculated using multivariate logistic regression analyses to determine adjusted odds ratios with 95% confidence intervals. Pediatric IRVs accounted for more than 11 million ED visits annually. The most common diagnoses for IRVs were open wounds, contusions, sprains and strains, and fractures and dislocations. The leading external causes of IRVs were sports-related injuries, accidental falls, being struck by objects, and motor vehicle collisions. Children with IRVs differed from those who presented for non-IRVs in many characteristics: they were more likely to be male, to be older, to be of white race, and to have private insurance, and less likely to be of Asian or Hispanic ethnicity. Sports and recreation are the leading external causes of pediatric IRVs to EDs in the United States. There are different patterns of IRVs according to gender, age, race, ethnicity, and insurance. Identification of specific patterns of injury is necessary for the design of effective prevention strategies.

  15. Acceptance of Ambulatory Laparoscopic Cholecystectomy in Central Switzerland.

    Science.gov (United States)

    Widjaja, Sandra P; Fischer, Henning; Brunner, Alexander R; Honigmann, Philipp; Metzger, Jürg

    2017-11-01

    Currently, most patients undergoing laparoscopic cholecystectomy (LC) in Switzerland are inpatients for 2-3 days. Due to a lack of available hospital beds, we asked whether day-case surgery would be an option for patients in central Switzerland. The questions of acceptability of outpatient LC and factors contributing to the acceptability thus arose. Hundred patients suffering from symptomatic cholecystolithiasis, capable of communicating in German, and between 18 and 65 years old, were included. Patients received a pre-operative questionnaire on medical history and social situation when informed consent on surgery and participation in the study was obtained. Exclusion criteria were patients suffering from acute cholecystitis or any type of cancer; having a BMI >40 kg/m 2 ; needing conversion to open cholecystectomy or an intraoperative drainage; and non-German speakers. Surgery was performed laparoscopically. Both surgeon and patient filled in a postoperative questionnaire. The surgeon's questionnaire listed medical and technical information, and the patients' questionnaire listed medical information, satisfaction with the treatment and willingness to be released on the same day. These data from both questionnaires were grouped into social and medical factors and analysed on their influence upon willingness to accept an ambulatory procedure. No outpatient follow-up apart from checking for readmission to our hospital within 1 month after discharge was performed. Of the 100 participants, one-third was male. More than two-thirds were Swiss citizens. Only one participant was ineligible for rapid release evaluation due to need of a drainage. Among the social factors contributing to the acceptability of ambulatory care, we found nationality to be relevant; Swiss citizens preferred an inpatient procedure, whereas non-Swiss citizens were significantly more willing to return home on the same day. Household size, sex and age did not correlate with a preference for

  16. The internal medicine clerkship and ambulatory learning experiences: results of the 2010 clerkship directors in internal medicine survey.

    Science.gov (United States)

    Shaheen, Amy; Papp, Klara K; Torre, Dario

    2013-01-01

    Education in the ambulatory setting should be an integral part of undergraduate medical education. However, previous studies have shown education in this setting has been lacking in medical school. Ambulatory education occurs on some internal medicine clerkships. The extent of this education is unclear. The purpose of this survey was to assess the structure, curriculum, assessment methods, and barriers to implementation of ambulatory education on the internal medicine clerkship. An annual survey of institutional members of the Clerkship Directors in Internal Medicine (CDIM) was done in April 2010. The data were anonymous and descriptive statistics were used to summarize responses. Free text results were analyzed using qualitative techniques. The response rate was 75%. The majority of respondents had a required ambulatory component to the clerkship. Ambulatory experiences distinct from the inpatient internal medicine experience were common (46%). Integration with either the inpatient experiences or other departmental clerkships also occurred. The majority of ambulatory educational experiences were with generalists (74%) and/or subspecialists (45%). The most common assessment tool was the National Board of Medical Examiners (NBME) ambulatory shelf exam. Thematic analysis of the question about how practice based learning was taught elicited four major themes: Not taught; taught in the context of learning evidence based medicine; taught while learning chronic disease management with quality improvement; taught while learning about health care finance. Barriers to implementation included lack of faculty and financial resources. There have been significant increases in the amount of time dedicated to ambulatory internal medicine. The numbers of medical schools with ambulatory internal medicine education has increased. Integration of the ambulatory experiences with other clerkships such as family medicine occurs. Curriculum was varied but difficulties with dissemination

  17. Office Visits to Monitor Stimulant Medication Safety and Efficacy: Recommended Care.

    Science.gov (United States)

    Zima, Bonnie T; Norquist, Grayson S; Altchuler, Steven I; Behrens, Jacob; Iles-Shih, Matthew D; Ng, Yiu Kee Warren; Schaepper, Mary Ann

    2018-06-01

    The clinical guidance based on the research article, "Specific Components of Pediatricians' Medication-Related Care Predict Attention-Deficit/Hyperactivity Disorder Improvement," published in the June 2017 issue, 1 might be premature. The authors, Epstein et al., suggest that "Physicians do not need to necessarily rely on office visits to monitor medication response and side effects in the week(s) after initially prescribing medication, but instead could use phone calls or email correspondence to check in with the family" (p. 489). However, this advice has the potential to be misinterpreted that phone or email contact is acceptable clinical practice to monitor stimulant medication safety and efficacy, especially during the maintenance phase. It also could be erroneously interpreted that phone or email contact is sufficient for follow-up care for children receiving medication treatment for attention-deficit/hyperactivity disorder (ADHD) for national quality measures. Copyright © 2018 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.

  18. An Anesthetist’s Experience and the Incidence of Critical Cases in Ambulatory Surgery

    Directory of Open Access Journals (Sweden)

    R. V. Bolshedvorov

    2009-01-01

    Full Text Available Objective: to evaluate the impact of experience on the quality of anesthesia in ambulatory surgery. Materials and methods. The authors undertook a study of the role of experience and specialization on the occurrence of complications in ambulatory anesthesia care. By using the internal audit and calculating the frequency of critical cases, they examined the results of the work of two groups of anesthetists: 1 medical beginners after 2-year adjunct practice and 2 one-day hospital specialists having an at least 7-year practice length. Results. In the beginner group, the number of critical cases per operation was twice higher than that in the experienced specialists. The paper shows the detrimental pattern of the residual principle in selecting anesthetists for work at a one-day hospital and provides evidence that specialization is required in the area under discussion. Key words: ambulatory anesthesiology, role of an anesthetist’s experience, critical cases.

  19. Anesthesia for Ambulatory Pediatric Surgery in Sub-Saharan Africa: A Pilot Study in Burkina Faso.

    Science.gov (United States)

    Kabré, Yvette B; Traoré, Idriss S S; Kaboré, Flavien A R; Ki, Bertille; Traoré, Alain I; Ouédraogo, Isso; Bandré, Emile; Wandaogo, Albert; Ouédraogo, Nazinigouba

    2017-02-01

    Long surgical wait times and limited hospital capacity are common obstacles to surgical care in many countries in Sub-Saharan Africa (SSA). Introducing ambulatory surgery might contribute to a solution to these problems. The purpose of this study was to evaluate the safety and feasibility of introducing ambulatory surgery into a pediatric hospital in SSA. This is a cross-sectional descriptive study that took place over 6 months. It includes all patients assigned to undergo ambulatory surgery in the Pediatric University Hospital in Ouagadougou, Burkina Faso. Eligibility criteria for the ambulatory surgery program included >1 year of age, American Society of Anesthesiologists (ASA) 1 status, surgery with a low risk of bleeding, lasting anesthesia with halothane. Sixty-five percent also received regional or local anesthesia consisting of caudal block in 79.23% or nerve block in 20.77%. The average duration of surgery was 33 ± 17.47 minutes. No intraoperative complications were noted. All the patients received acetaminophen and a nonsteroidal anti-inflammatory drug in the recovery room. Twelve (11.7%) patients had complications in recovery, principally nausea and vomiting. Eight (7.8%) patients were admitted to the hospital. No serious complications were associated with ambulatory surgery. Its introduction could possibly be a solution to improving pediatric surgical access in low-income countries.

  20. Effects of health information exchange adoption on ambulatory testing rates.

    Science.gov (United States)

    Ross, Stephen E; Radcliff, Tiffany A; Leblanc, William G; Dickinson, L Miriam; Libby, Anne M; Nease, Donald E

    2013-01-01

    To determine the effects of the adoption of ambulatory electronic health information exchange (HIE) on rates of laboratory and radiology testing and allowable charges. Claims data from the dominant health plan in Mesa County, Colorado, from 1 April 2005 to 31 December 2010 were matched to HIE adoption data on the provider level. Using mixed effects regression models with the quarter as the unit of analysis, the effect of HIE adoption on testing rates and associated charges was assessed. Claims submitted by 306 providers in 69 practices for 34 818 patients were analyzed. The rate of testing per provider was expressed as tests per 1000 patients per quarter. For primary care providers, the rate of laboratory testing increased over the time span (baseline 1041 tests/1000 patients/quarter, increasing by 13.9 each quarter) and shifted downward with HIE adoption (downward shift of 83, prates or imputed charges in either provider group. Ambulatory HIE adoption is unlikely to produce significant direct savings through reductions in rates of testing. The economic benefits of HIE may reside instead in other downstream outcomes of better informed, higher quality care.

  1. Predictors of Better Self-Care in Patients with Heart Failure after Six Months of Follow-Up Home Visits

    Science.gov (United States)

    Trojahn, Melina Maria; Ruschel, Karen Brasil; Nogueira de Souza, Emiliane; Mussi, Cláudia Motta; Naomi Hirakata, Vânia; Nogueira Mello Lopes, Alexandra; Rabelo-Silva, Eneida Rejane

    2013-01-01

    This study aimed to examine the predictors of better self-care behavior in patients with heart failure (HF) in a home visiting program. This is a longitudinal study nested in a randomized controlled trial (ISRCTN01213862) in which the home-based educational intervention consisted of a six-month followup that included four home visits by a nurse, interspersed with four telephone calls. The self-care score was measured at baseline and at six months using the Brazilian version of the European Heart Failure Self-Care Behaviour Scale. The associations included eight variables: age, sex, schooling, having received the intervention, social support, income, comorbidities, and symptom severity. A simple linear regression model was developed using significant variables (P ≤ 0.20), followed by a multivariate model to determine the predictors of better self-care. One hundred eighty-eight patients completed the study. A better self-care behavior was associated with patients who received intervention (P < 0.001), had more years of schooling (P = 0.016), and had more comorbidities (P = 0.008). Having received the intervention (P < 0.001) and having a greater number of comorbidities (P = 0.038) were predictors of better self-care. In the multivariate regression model, being in the intervention group and having more comorbidities were a predictor of better self-care. PMID:24083023

  2. Life satisfaction and frequency of doctor visits.

    Science.gov (United States)

    Kim, Eric S; Park, Nansook; Sun, Jennifer K; Smith, Jacqui; Peterson, Christopher

    2014-01-01

    Identifying positive psychological factors that reduce health care use may lead to innovative efforts that help build a more sustainable and high-quality health care system. Prospective studies indicate that life satisfaction is associated with good health behaviors, enhanced health, and longer life, but little information about the association between life satisfaction and health care use is available. We tested whether higher life satisfaction was prospectively associated with fewer doctor visits. We also examined potential interactions between life satisfaction and health behaviors. Participants were 6379 adults from the Health and Retirement Study, a prospective and nationally representative panel study of American adults older than 50 years. Participants were tracked for 4 years. We analyzed the data using a generalized linear model with a gamma distribution and log link. Higher life satisfaction was associated with fewer doctor visits. On a 6-point life satisfaction scale, each unit increase in life satisfaction was associated with an 11% decrease in doctor visits--after adjusting for sociodemographic factors (relative risk = 0.89, 95% confidence interval = 0.86-0.93). The most satisfied respondents (n = 1121; 17.58%) made 44% fewer doctor visits than did the least satisfied (n = 182; 2.85%). The association between higher life satisfaction and reduced doctor visits remained even after adjusting for baseline health and a wide range of sociodemographic, psychosocial, and health-related covariates (relative risk = 0.96, 95% confidence interval = 0.93-0.99). Higher life satisfaction is associated with fewer doctor visits, which may have important implications for reducing health care costs.

  3. 78 FR 56711 - Health Insurance Exchanges; Application by the Accreditation Association for Ambulatory Health...

    Science.gov (United States)

    2013-09-13

    ... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-9953-PN] Health Insurance Exchanges; Application by the Accreditation Association for Ambulatory Health Care To Be... Federal Register announcing the result of our determination. (Health Insurance Exchanges; Application by...

  4. 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

    Directory of Open Access Journals (Sweden)

    Daniele Favaro Ribeiro

    2009-12-01

    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.

  5. Schedules for home visits in the early postpartum period.

    Science.gov (United States)

    Yonemoto, Naohiro; Dowswell, Therese; Nagai, Shuko; Mori, Rintaro

    2017-08-02

    Maternal complications including psychological and mental health problems and neonatal morbidity have been commonly observed in the postpartum period. Home visits by health professionals or lay supporters in the weeks following the birth may prevent health problems from becoming chronic with long-term effects on women, their babies, and their families. To assess outcomes for women and babies of different home-visiting schedules during the early postpartum period. The review focuses on the frequency of home visits, the duration (when visits ended) and intensity, and on different types of home-visiting interventions. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and reference lists of retrieved articles. Randomised controlled trials (RCTs) (including cluster-RCTs) comparing different types of home-visiting interventions enrolling participants in the early postpartum period (up to 42 days after birth). We excluded studies in which women were enrolled and received an intervention during the antenatal period (even if the intervention continued into the postnatal period) and studies recruiting only women from specific high-risk groups. (e.g. women with alcohol or drug problems). Study eligibility was assessed by at least two review authors. Data extraction and assessment of risk of bias were carried out independently by at least two review authors. Data were entered into Review Manager software. We included data from 12 randomised trials with data for more than 11,000 women. The trials were carried out in countries across the world, and in both high- and low-resource settings. In low-resource settings women receiving usual care may have received no additional postnatal care after early hospital discharge.The interventions and control conditions varied considerably across studies with trials focusing on three broad types of comparisons: schedules involving more versus fewer postnatal home visits (five studies), schedules

  6. Ambulatory surgery center market share and rates of outpatient surgery in the elderly.

    Science.gov (United States)

    Hollenbeck, Brent K; Hollingsworth, John M; Dunn, Rodney L; Zaojun Ye; Birkmeyer, John D

    2010-12-01

    Relative to outpatient surgery in hospital settings, ambulatory surgery centers (ASCs) are more efficient and associated with a lower cost per case. However, these facilities may also spur higher overall procedure utilization and thus lead to greater overall health care costs. The authors used the State Ambulatory Surgery Database from the State of Florida to identify Medicare-aged patients undergoing 4 common ambulatory procedures in 2006, including knee arthroscopy, cystoscopy, cataract removal, and colonoscopy. Hospital service areas (HSAs) were characterized according to ASC market share, that is, the proportion of residents undergoing outpatient surgery in these facilities. The authors then examined relationships between ASC market share and rates of each procedure. Age-adjusted rates of ambulatory surgery ranged from 190.5 cases per 1000 to 320.8 cases per 1000 in HSAs with low and high ASC market shares, respectively (P market share. The greatest difference, both in relative and absolute terms, was observed for patients undergoing cystoscopy. In areas of high ASC market share, the age-adjusted rate of cystoscopy was nearly 3-fold higher than in areas with low ASC market share (34.5 vs 11.9 per 1000 population; P elderly. Whether ASCs are meeting unmet clinical demand or spurring overutilization is not clear.

  7. Reliability of Patient-Led Screening with the Malnutrition Screening Tool: Agreement between Patient and Health Care Professional Scores in the Cancer Care Ambulatory Setting.

    Science.gov (United States)

    Di Bella, Alexandra; Blake, Claire; Young, Adrienne; Pelecanos, Anita; Brown, Teresa

    2018-02-01

    The prevalence of malnutrition in patients with cancer is reported as high as 60% to 80%, and malnutrition is associated with lower survival, reduced response to treatment, and poorer functional status. The Malnutrition Screening Tool (MST) is a validated tool when administered by health care professionals; however, it has not been evaluated for patient-led screening. This study aims to assess the reliability of patient-led MST screening through assessment of inter-rater reliability between patient-led and dietitian-researcher-led screening and intra-rater reliability between an initial and a repeat patient screening. This cross-sectional study included 208 adults attending ambulatory cancer care services in a metropolitan teaching hospital in Queensland, Australia, in October 2016 (n=160 inter-rater reliability; n=48 intra-rater reliability measured in a separate sample). Primary outcome measures were MST risk categories (MST 0-1: not at risk, MST ≥2: at risk) as determined by screening completed by patients and a dietitian-researcher, patient test-retest screening, and patient acceptability. Percent and chance-corrected agreement (Cohen's kappa coefficient, κ) were used to determine agreement between patient-MST and dietitian-MST (inter-rater reliability) and MST completed by patient on admission to unit (patient-MSTA) and MST completed by patient 1 to 3 hours after completion of initial MST (patient-MSTB) (intra-rater reliability). High inter-rater reliability and intra-rater reliability were observed. Agreement between patient-MST and dietitian-MST was 96%, with "almost perfect" chance-adjusted agreement (κ=0.92, 95% CI 0.84 to 0.97). Agreement between repeated patient-MSTA and patient-MSTB was 94%, with "almost perfect" chance-adjusted agreement (κ=0.88, 95% CI 0.71 to 1.00). Based on dietitian-MST, 33% (n=53) of patients were identified as being at risk for malnutrition, and 40% of these reported not seeing a dietitian. Of 156 patients who provided

  8. New antithrombotic agents in the ambulatory setting.

    Science.gov (United States)

    Gibbs, Neville M; Weightman, William M; Watts, Stephen A

    2014-12-01

    Many patients presenting for surgical or other procedures in an ambulatory setting are taking new antiplatelet or anticoagulant agents. This review assesses how the novel features of these new agents affect the management of antithrombotic therapy in the ambulatory setting. There have been very few studies investigating the relative risks of continuing or ceasing new antithrombotic agents. Recent reviews indicate that the new antithrombotic agents offer greater efficacy or ease of administration but are more difficult to monitor or reverse. They emphasize the importance of assessing the bleeding risk of the procedure, the thrombotic risk if the agent is ceased, and patient factors that increase the likelihood of bleeding. The timing of cessation of the agent, if required, depends on its pharmacokinetics and patients' bleeding risks. Patients at high risk of thrombotic complications may require bridging therapy. Once agreed upon, the perioperative plan should be made clear to all involved. As there are few clinical studies to guide management, clinicians must make rational decisions in relation to continuing or ceasing new antithrombotic agents. This requires knowledge of their pharmacokinetics, and a careful multidisciplinary assessment of the relative thrombotic and bleeding risks in individual patients.

  9. Home visit delegation in primary care: acceptability to general practitioners in the state of Mecklenburg-Western Pomerania, Germany.

    Science.gov (United States)

    Dini, Lorena; Sarganas, Giselle; Heintze, Christoph; Braun, Vittoria

    2012-11-01

    Shortages and maldistribution of primary care physicians (PCPs) are affecting many countries today, including in Germany. As has been suggested, the ensuing problems might be alleviated by delegating some medical tasks to physicians' assistants (PAs). This was tried in three regions of the German state of Mecklenburg-Western Pomerania under a pilot project entitled AGnES (Arztentlastende gemeindenahe E-Health-gestützte Systemische Intervention, i.e., a community-based, e-health-assisted, systemic intervention to reduce physicians' workloads). We conducted a survey of all practicing PCPs in the state to assess their overall attitude toward the delegation of home visit tasks, and to determine what they would prefer as the job description and type of employment contract for a PA who would be hired to assist them. All PCPs practicing in Mecklenburg-Western Pomerania were asked in a quantitative survey about their willingness to delegate home visits, their perceived barriers to and benefits of home visit delegation to a qualified assistant, the skills they would require of a PA who would be hired to carry out home visits, and their preferred type of employment contract for the PA. 47% of the PCPs (515/1096) responded to the survey. 46% of the respondents were already informally delegating home visit tasks to qualified PAs. Female PCPs were more likely to do so (odds ratio [OR] 1.70), as were PCPs practicing in rural areas (OR 1.63) and those working in individual practice (OR 1.94). Most PCPs were in favor of delegating home visits to qualified PAs (77%). Main advantages were seen in reducing physicians' workloads (70%) and in increasing their job satisfaction (48%). 34% of PCPs said they would not cover the cost of training PAs. Acceptance of home visit delegation among PCPs in the state of Mecklenburg-Western Pomerania is high, mainly among the younger physicians. Perceived barriers and benefits of delegation of home visits to qualified PAs should be taken into

  10. Blood Pressure Measurement: Clinic, Home, Ambulatory, and Beyond

    Science.gov (United States)

    Drawz, Paul E.; Abdalla, Mohamed; Rahman, Mahboob

    2014-01-01

    Blood pressure has traditionally been measured in the clinic setting using the auscultory method and a mercury sphygmomanometer. Technological advances have led to improvements in measuring clinic blood pressure and allowed for measuring blood pressures outside the clinic. This review outlines various methods for evaluating blood pressure and the clinical utility of each type of measurement. Home blood pressures and 24 hour ambulatory blood pressures have improved our ability to evaluate risk for target organ damage and hypertension related morbidity and mortality. Measuring home blood pressures may lead to more active participation in health care by patients and has the potential to improve blood pressure control. Ambulatory blood pressure monitoring enables the measuring nighttime blood pressures and diurnal changes, which may be the most accurate predictors of risk associated with elevated blood pressure. Additionally, reducing nighttime blood pressure is feasible and may be an important component of effective antihypertensive therapy. Finally, estimating central aortic pressures and pulse wave velocity are two of the newer methods for assessing blood pressure and hypertension related target organ damage. PMID:22521624

  11. Optimizing the design of preprinted orders for ambulatory chemotherapy: combining oncology, human factors, and graphic design.

    Science.gov (United States)

    Jeon, Jennifer; White, Rachel E; Hunt, Richard G; Cassano-Piché, Andrea L; Easty, Anthony C

    2012-03-01

    To establish a set of guidelines for developing ambulatory chemotherapy preprinted orders. Multiple methods were used to develop the preprinted order guidelines. These included (A) a comprehensive literature review and an environmental scan; (B) analyses of field study observations and incident reports; (C) critical review of evidence from the literature and the field study observation analyses; (D) review of the draft guidelines by a clinical advisory group; and (E) collaboration with graphic designers to develop sample preprinted orders, refine the design guidelines, and format the resulting content. The Guidelines for Developing Ambulatory Chemotherapy Preprinted Orders, which consist of guidance on the design process, content, and graphic design elements of ambulatory chemotherapy preprinted orders, have been established. Health care is a safety critical, dynamic, and complex sociotechnical system. Identifying safety risks in such a system and effectively addressing them often require the expertise of multiple disciplines. This study illustrates how human factors professionals, clinicians, and designers can leverage each other's expertise to uncover commonly overlooked patient safety hazards and to provide health care professionals with innovative, practical, and user-centered tools to minimize those hazards.

  12. Low bone mineral density in ambulatory persons with cerebral palsy? A systematic review.

    Science.gov (United States)

    Mus-Peters, Cindy T R; Huisstede, Bionka M A; Noten, Suzie; Hitters, Minou W M G C; van der Slot, Wilma M A; van den Berg-Emons, Rita J G

    2018-05-22

    Non-ambulatory persons with cerebral palsy are prone to low bone mineral density. In ambulatory persons with cerebral palsy, bone mineral density deficits are expected to be small or absent, but a consensus conclusion is lacking. In this systematic review bone mineral density in ambulatory persons with cerebral palsy (Gross Motor Function Classification Scales I-III) was studied. Medline, Embase, and Web of Science were searched. According to international guidelines, low bone mineral density was defined as Z-score ≤ -2.0. In addition, we focused on Z-score ≤ -1.0 because this may indicate a tendency towards low bone mineral density. We included 16 studies, comprising 465 patients aged 1-65 years. Moderate and conflicting evidence for low bone mineral density (Z-score ≤ -2.0) was found for several body parts (total proximal femur, total body, distal femur, lumbar spine) in children with Gross Motor Function Classification Scales II and III. We found no evidence for low bone mineral density in children with Gross Motor Function Classification Scale I or adults, although there was a tendency towards low bone mineral density (Z-score ≤ -1.0) for several body parts. Although more high-quality research is needed, results indicate that deficits in bone mineral density are not restricted to non-ambulatory people with cerebral palsy. Implications for Rehabilitation Although more high-quality research is needed, including adults and fracture risk assessment, the current study indicates that deficits in bone mineral density are not restricted to non-ambulatory people with CP. Health care professionals should be aware that optimal nutrition, supplements on indication, and an active lifestyle, preferably with weight-bearing activities, are important in ambulatory people with CP, also from a bone quality point-of-view. If indicated, medication and fall prevention training should be prescribed.

  13. Innovative solutions--the art of improvisation: patient and family preferences for visitation in critical care.

    Science.gov (United States)

    Heitman, Linda; McClard, Catherine

    2009-01-01

    Critical care nurses identified that, although a liberal visitation policy was followed, patients and families occasionally expressed preferences for verbal communication, rather than have the visitor physically present in the unit. Previously tested communication devices interfered with operating equipment resulting in poor reception. The purpose of this project was to find an effective method for patients to verbally communicate with visitors.

  14. The Use of Ambulatory Blood Pressure Monitoring As Standard of Care in Pediatrics

    Science.gov (United States)

    Peterson, Caitlin G.; Miyashita, Yosuke

    2017-01-01

    Hypertension (HTN) is a significant global health problem, responsible for 7.5 million deaths each year worldwide. The prevalence of HTN is increasing in the pediatric population likely attributed to the increase in childhood obesity. Recent work has also shown that blood pressure (BP) tends to track from childhood to adulthood including BP-related target organ damage. In the last 25–30 years, pediatric use of ambulatory blood pressure monitoring (ABPM) has been expanding mainly in the setting of initial elevated BP measurement evaluation, HTN therapy efficacy follow-up, and renal disease. However, there are many clinical areas where ABPM could potentially be used but is currently underutilized. This review summarizes the current knowledge and the uses of pediatric ABPM and explores clinical areas where it can be very useful both to detect HTN and its longitudinal follow-up. And thus, ABPM could serve as a critical tool to potentially prevent early cardiovascular mortality and morbidity in wide variety of populations. With solid data to support ABPM’s superiority over clinic BP measurements and these clinical areas for its expansion, ABPM should now be part of standard of care in BP evaluation and management in pediatrics. PMID:28713799

  15. Challenges in pediatric ambulatory anesthesia: kids are different.

    Science.gov (United States)

    Collins, Corey E; Everett, Lucinda L

    2010-06-01

    The care of the child having ambulatory surgery presents a specific set of challenges to the anesthesia provider. This review focuses on areas of clinical distinction that support the additional attention children often require, and on clinical controversies that require providers to have up-to-date information to guide practice and address parental concerns. These include perioperative risk; obstructive sleep apnea; obesity; postoperative nausea and vomiting; neurocognitive outcomes; and specific concerns regarding common ear, nose, and throat procedures. Copyright (c) 2010 Elsevier Inc. All rights reserved.

  16. Ambulatory blood pressure monitoring for hypertension in general practice.

    OpenAIRE

    Taylor, R S; Stockman, J; Kernick, D; Reinhold, D; Shore, A C; Tooke, J E

    1998-01-01

    Ambulatory blood pressure monitoring (ABPM) is being increasingly used in general practice. There is at present little published evidence regarding the clinical utility of ABPM in the care of patients with established hypertension in this setting. We examined this issue by undertaking ABPM in a group of patients with established hypertension. 40 patients (aged 33-60 years) currently being treated for hypertension were randomly selected from a general practice list and underwent a single 24-ho...

  17. Anesthesiologists' practice patterns for treatment of postoperative nausea and vomiting in the ambulatory Post Anesthesia Care Unit

    Directory of Open Access Journals (Sweden)

    Claybon Louis

    2006-06-01

    Full Text Available Abstract Background When patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV. Only until recently have there been any published recommendations, mostly derived from expert opinion, as to which regimens to use once a patient develops PONV. The goal of this study was to assess the responses to a written survey to address the following questions: 1 If no prophylaxis is administered to an ambulatory patient, what agent do anesthesiologists use for treatment of PONV in the ambulatory Post-Anesthesia Care Unit (PACU?; 2 Do anesthesiologists use non-pharmacologic interventions for PONV treatment?; and 3 If a PONV prophylaxis agent is administered during the anesthetic, do anesthesiologists choose an antiemetic in a different class for treatment? Methods A questionnaire with five short hypothetical clinical vignettes was mailed to 300 randomly selected USA anesthesiologists. The types of pharmacological and nonpharmacological interventions for PONV treatment were analyzed. Results The questionnaire was completed by 106 anesthesiologists (38% response rate, who reported that on average 52% of their practice was ambulatory. If a patient develops PONV and received no prophylaxis, 67% (95% CI, 62% – 79% of anesthesiologists reported they would administer a 5-HT3-antagonist as first choice for treatment, with metoclopramide and dexamethasone being the next two most common choices. 65% (95% CI, 55% – 74% of anesthesiologists reported they would also use non-pharmacologic interventions to treat PONV in the PACU, with an IV fluid bolus or nasal cannula oxygen being the most common. When PONV prophylaxis was given during the anesthetic, the preferred PONV treatment choice changed. Whereas 3%–7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% (95% confidence intervals, 18% – 36% of practitioners would re

  18. VA Outpatient Visits by Administrative Parent, FY2010-2014

    Data.gov (United States)

    Department of Veterans Affairs — Outpatient visits by Administrative Parent. A visit is counted as a visit to one or more clinics or units within 1 calendar day at the site of care level. A patient...

  19. Ambulatory percutaneous nephrolithotomy: initial series.

    Science.gov (United States)

    Shahrour, Walid; Andonian, Sero

    2010-12-01

    To assess the safety and feasibility of ambulatory percutaneous nephrolithotomy (PCNL). PCNL is the gold standard for the management of large renal stones. Although tubeless PCNL has been previously described, no case series have been published of ambulatory PCNL. The criteria for ambulatory PCNL were: single tract, stone-free status documented by flexible nephroscopy, adequate pain control, and satisfactory postoperative hematocrit level and chest radiographic findings. Patient information, including operating room and fluoroscopy times, stone size and Hounsfield units, and number of needle punctures, were collected prospectively. The time spent in the recovery room, in addition to the amount of narcotics used in the recovery room and at home, was documented. Of 10 patients, 8 had nephrostomy tracts established intraoperatively by the urologist and 2 had preoperative nephrostomy tubes placed. The median operating and fluoroscopy time was 83.5 and 4.45 minutes, respectively. The median stone diameter was 20 mm (800 Hounsfield units) in addition to a patient with a staghorn calculus. The patients spent a median of 240 minutes in the recovery room and had received a median of 19.25 mg of morphine equivalents. Only 3 patients (30%) used narcotics at home. No intraoperative complications occurred, and none of the patients required transfusions. Two postoperative complications developed: a deep vein thrombosis requiring outpatient anticoagulation and multiresistant Escherichia coli infection requiring intravenous antibiotics. In highly selected patients, ambulatory PCNL is safe and feasible. More patients are needed to verify the criteria for patients undergoing the ambulatory approach. Copyright © 2010 Elsevier Inc. All rights reserved.

  20. Motivation to take part in integrated care – an assessment of follow-up home visits to elderly persons

    DEFF Research Database (Denmark)

    Hjelmar, U; Hendriksen, Carsten; Hansen, K

    2011-01-01

    to implement because of a number of organizational obstacles, including co-ordination between the organizations involved in the process. In this paper we look at the factors that affect motivation to participate in a cross-sectoral programme in Copenhagen, Denmark, implementing follow-up home visits to elderly...... persons. Theory and methods: The analysis is based on inter-organizational network theory in an attempt to explain the role of motivation in network formation between organizational systems. The empirical findings are based on focus groups and in-depth interviews with hospital staff, general practitioners...... understanding of values and learning potentials. Conclusions: The study concludes that we need to focus on specific care fields and actors to reduce complexity in the area and more fully understand what motivates care providers to participate in cross-sectoral activities, such as a follow-up home visit...

  1. Health Care Delivery.

    Science.gov (United States)

    Starfield, Barbara

    1987-01-01

    The article reviews emerging health care delivery options for handicapped children. Cost structures, quality of care, and future prospects are considered for Health Maintenance Organizations, Preferred Provider Organizations, Tax Supported Direct Service Programs, Hospital-Based Services, and Ambulatory Care Organizations. (Author/DB)

  2. Concomitant use of opioid medications with triptans or serotonergic antidepressants in US office-based physician visits.

    Science.gov (United States)

    Molina, Kyle C; Fairman, Kathleen A; Sclar, David A

    2018-01-01

    Opioids are not recommended for routine treatment of migraine because their benefits are outweighed by risks of medication overuse headache and abuse/dependence. A March 2016 US Food and Drug Administration (FDA) safety communication warned of the risk of serotonin syndrome from using opioids concomitantly with 5-hydroxytryptamine receptor agonists (triptans) or serotonergic antidepressants: selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Epidemiological information about co-prescribing of these medications is limited. The objective of this study was to estimate the nationwide prevalence of co-prescribing of an opioid with a serotonergic antidepressant and/or triptan in US office-based physician visits made by 1) all patients and 2) patients diagnosed with migraine. National Ambulatory Medical Care Survey (NAMCS) data were obtained for 2013 and 2014. Physician office visits that included the new or continued prescribing of ≥1 opioid medication with a triptan or an SSRI/SNRI were identified. Co-prescribed opioids were stratified by agent to determine the proportion of co-prescriptions with opioids posing a higher risk of serotonergic agonism (meperidine, tapentadol, and tramadol). Of an annualized mean 903.6 million office-based physician visits in 2013-2014, 17.7 million (2.0% of all US visits) resulted in the prescribing of ≥1 opioid medication with a triptan or an SSRI/SNRI. Opioid-SSRI/SNRI was co-prescribed in 16,044,721 visits, while opioid-triptan was co-prescribed in 1,622,827 visits. One-fifth of opioid co-prescribing was attributable to higher-risk opioids, predominantly tramadol (18.6% of opioid-SSRI/SNRI, 21.8% of opioid-triptan). Of 7,672,193 visits for patients diagnosed with migraine, 16.3% included opioid prescribing and 2.0% included co-prescribed opioid-triptan. During a period approximately 2 years prior to an FDA warning about the risk of serotonin syndrome from opioid-SSRI/SNRI or

  3. [Certification of an ambulatory gastroenterologic service fulfilling ISO Law 9001--criteria and national guidelines of the Gastroenterologic Association].

    Science.gov (United States)

    Birkner, B

    2000-09-01

    The objectives of certification and accreditation are the deployment and examination of quality improvement measures in health care services. The quality management system of the ISO 9001 is created to install measures and tools leading to assured and improved quality in health care. Only some experiences with certification fulfilling ISO 9001 criteria exist in the German health care system. Evidence-based clinical guidelines can serve as references for the development of standards in quality measurement. Only little data exists on the implementation strategy of guidelines and evaluation, respectively. A pilot quality management system in consistence with ISO 9001 criteria was developed for ambulatory, gastroenterological services. National guidelines of the German Society of Gastroenterology and Metabolism and the recommendations of the German Association of Physicians for quality assurance of gastrointestinal endoscopy were included in the documentation and internal auditing. This pilot quality management system is suitable for the first steps in the introduction of quality management in ambulatory health care. This system shows validity for accreditation and certification of gastrointestinal health care units as well.

  4. Diabetic foot wound care practices among patients visiting a tertiary care hospital in north India

    Directory of Open Access Journals (Sweden)

    Samreen Khan

    2016-09-01

    Full Text Available Background: Diabetic foot syndrome is one of the most common and devastating preventable complications of diabetes resulting in major economic consequences for the patients, their families, and the society. Aims & Objectives: The present study was carried out to assess knowledge, attitude and practices of Diabetic Foot Wound Care among the patients suffering from Diabetic Foot and to correlate them with the socio-demographic parameters. Material & Methods: It was a Hospital based cross-sectional study involving clinically diagnosed adult (>18 years patients of Diabetic Foot visiting the Surgery and Medicine OPDs at Teerthankar Mahaveer Medical College & Research Centre, Moradabad, India. Results: Significant association KAP (Knowledge, Attitude and Practices score was seen with age of the patient, education, addiction, family history of Diabetes Mellitus, prior receipt of information regarding Diabetic foot-care practices, compliance towards the treatment and the type of foot wear used. Conclusions: The results highlight areas especially Health education, use of safe footwear and life style adjustments, where efforts to improve knowledge and practice may contribute to the prevention of development of Foot ulcers and amputation. 

  5. Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey for ambulatory surgical centers - Facility

    Data.gov (United States)

    U.S. Department of Health & Human Services — A list of ambulatory surgical center ratings for the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey....

  6. Life Satisfaction and Frequency of Doctor Visits

    Science.gov (United States)

    Kim, Eric S.; Park, Nansook; Sun, Jennifer K.; Smith, Jacqui; Peterson, Christopher

    2015-01-01

    Objective Identifying positive psychological factors that reduce health care use may lead to innovative efforts that help build a more sustainable and high quality health care system. Prospective studies indicate that life satisfaction is associated with good health behaviors, enhanced health, and longer life, but little information is available about the association between life satisfaction and health care use. We tested whether higher life satisfaction was prospectively associated with fewer doctor visits. We also examined potential interactions between life satisfaction and health behaviors. Methods Participants were 6,379 adults from the Health and Retirement Study, a prospective and nationally representative panel study of American adults over the age of 50. Participants were tracked for four years. We analyzed the data using a generalized linear model with a gamma distribution and log link. Results Higher life satisfaction was associated with fewer doctor visits. On a six-point life satisfaction scale, each unit increase in life satisfaction was associated with an 11% decrease in doctor visits—after adjusting for sociodemographic factors (RR = 0.89, 95% CI = 0.86 to 0.93). The most satisfied respondents (N=1,121; 17.58%) made 44% fewer doctor visits than the least satisfied (N=182; 2.85%). The association between higher life satisfaction and reduced doctor visits remained even after adjusting for baseline health and a wide range of sociodemographic, psychosocial, and health-related covariates (RR = 0.96, 95% CI = 0.93 to 0.99). Conclusions Higher life satisfaction is associated with fewer doctor visits, which may have important implications for reducing health care costs. PMID:24336427

  7. Unplanned Hospital Visits - National

    Data.gov (United States)

    U.S. Department of Health & Human Services — Unplanned Hospital Visits – national data. This data set includes national-level data for the hospital return days (or excess days in acute care) measures, the...

  8. Motivation to take part in integrated care - an assessment of follow-up home visits to elderly persons

    Directory of Open Access Journals (Sweden)

    Ulf Hjelmar

    2011-08-01

    Full Text Available Objectives: The aim of follow-up visits by the general practitioner and district nurse (within a week after discharge from hospital is to reduce hospital readmissions and improve the overall wellbeing of the patient. There is strong evidence that these programmes are effective, but are difficult to implement because of a number of organizational obstacles, including co-ordination between the organizations involved in the process. In this paper we look at the factors that affect motivation to participate in a cross-sectoral programme in Copenhagen, Denmark, implementing follow-up home visits to elderly persons. Theory and methods: The analysis is based on inter-organisational network theory in an attempt to explain the role of motivation in network formation between organizational systems. The empirical findings are based on focus groups and in-depth interviews with hospital staff, general practitioners, and district nurses. Results: Care providers are motivated to collaborate by a number of factors. The focus of collaboration needs to be clearly defined and agreed upon, there needs to be a high degree of equality between the professionals involved, and there has to be a will to co-operate based on a shared understanding of values and learning potentials. Conclusions: The study concludes that we need to focus on specific care fields and actors to reduce complexity in the area and more fully understand what motivates care providers to participate in cross-sectoral activities such as a follow-up home visit programme. One lesson for current policy is that motivational factors need to be addressed in future collaborative programs in order to fully exploit the potential health benefits.

  9. Motivation to take part in integrated care - an assessment of follow-up home visits to elderly persons

    Directory of Open Access Journals (Sweden)

    Ulf Hjelmar

    2011-08-01

    Full Text Available Objectives: The aim of follow-up visits by the general practitioner and district nurse (within a week after discharge from hospital is to reduce hospital readmissions and improve the overall wellbeing of the patient. There is strong evidence that these programmes are effective, but are difficult to implement because of a number of organizational obstacles, including co-ordination between the organizations involved in the process. In this paper we look at the factors that affect motivation to participate in a cross-sectoral programme in Copenhagen, Denmark, implementing follow-up home visits to elderly persons.Theory and methods: The analysis is based on inter-organisational network theory in an attempt to explain the role of motivation in network formation between organizational systems. The empirical findings are based on focus groups and in-depth interviews with hospital staff, general practitioners, and district nurses.Results: Care providers are motivated to collaborate by a number of factors. The focus of collaboration needs to be clearly defined and agreed upon, there needs to be a high degree of equality between the professionals involved, and there has to be a will to co-operate based on a shared understanding of values and learning potentials.Conclusions: The study concludes that we need to focus on specific care fields and actors to reduce complexity in the area and more fully understand what motivates care providers to participate in cross-sectoral activities such as a follow-up home visit programme. One lesson for current policy is that motivational factors need to be addressed in future collaborative programs in order to fully exploit the potential health benefits.

  10. New concepts and technologies in home care and ambulatory monitoring.

    Science.gov (United States)

    Dittmar, A; Axisa, F; Delhomme, G; Gehin, C

    2004-01-01

    The world is becoming more and more health conscious. Society, health policy and patients' needs are all changing dramatically. The challenges society is currently facing are related to the increase in the aging population, changes in lifestyle, the need for healthcare cost containment and the need for improvement and monitoring of healthcare quality. The emphasis is put on prevention rather than on treatment. In addition, patients and health consumers are waiting for non-invasive or minimally-invasive diagnosis and treatment methods, for home care, short stays in hospital, enhancement of rehabilitation, information and involvement in their own treatment. Progress in science and technology offers, today, miniaturization, speed, intelligence, sophistication and new materials at lower cost. In this new landscape, microtechnologies, information technologies and telecommunications are key factors. Telemedicine has also evolved. Used initially to exchange patients' files, radiographic data and other information between health providers, today telemedicine contributes to new trends in "hospital extension" through all-day monitoring of vital signs, professional activities, entertainment and home-based activities. The new possibilities for home care and ambulatory monitoring are provided at 4 levels: a) Microsensors. Microtechnologies offer the possibility of small size, but also of intelligent, active devices, working with low energy, wireless and non-invasive or minimally-invasive; b) Wrist devices are particularly user friendly and combine sensors, circuits, supply, display and wireless transmission in a single box, very convenient for common physical activities; c) Health smart clothes make contact with 90 % of the skin and offer many possibilities for the location of sensors. These sensors have to be thin, flexible and compatible with textiles, or made using textile technologies, such as new fibers with specific (mechanical, electrical and optical) properties; d

  11. Physician visits and preventive care among Asian American and Pacific Islander long-term survivors of colorectal cancer, USA, 1996-2006.

    Science.gov (United States)

    Steele, C Brooke; Townsend, Julie S; Tai, Eric; Thomas, Cheryll C

    2014-03-01

    Published literature on receipt of preventive healthcare services among Asian American and Pacific Islander (API) cancer survivors is scarce. We describe patterns in receipt of preventive services among API long-term colorectal cancer (CRC) survivors. Surveillance, Epidemiology, and End Results registry-Medicare data were used to identify 9,737 API and white patients who were diagnosed with CRC during 1996-2000 and who survived 5 or more years beyond their diagnoses. We examined receipt of vaccines, mammography (females), bone densitometry (females), and cholesterol screening among the survivors and how the physician specialties they visited for follow-up care correlated to services received. APIs were less likely than whites to receive mammography (52.0 vs. 69.3 %, respectively; P Women who visited both PCPs and oncologists compared with PCPs only were more likely to receive mammography (odds ratio = 1.40; 95 % confidence interval, 1.05-1.86). Visits to both PCPs and oncologists were associated with increased use of mammography. Although API survivors visited these specialties more frequently than white survivors, API women may need culturally appropriate outreach to increase their use of this test. Long-term cancer survivors need to be aware of recommended preventive healthcare services, as well as who will manage their primary care and cancer surveillance follow-up.

  12. Effectiveness of locomotion training in a home visit preventive care project: one-group pre-intervention versus post-intervention design study.

    Science.gov (United States)

    Ito, Shinya; Hashimoto, Mari; Aduma, Saori; Yasumura, Seiji

    2015-11-01

    Locomotion training in a home visit-type preventive-care program has been reported elsewhere. However, continuation of appropriate exercises in a home setting is difficult, and few reports are available on locomotion training in a home setting. The objective of this study was to evaluate the effectiveness of locomotion training over 3 months in a home visit-type preventive-care program for improvement of motor function among elderly people. Nine hundred and fifty-eight elderly people in Tendo City in Japan who were not currently attending any preventive-care program were invited to participate in the study, and 87 were enrolled. In the pre-intervention and post-intervention assessments, we administered an interview survey (the Kihon Checklist), the timed one-leg standing test with eyes open and the sit-to-stand test, at the participants' homes. The intervention involved one set of training exercises with the participants standing on each leg for 1 min and squatting five or six times. The participants were asked to repeat one set of the exercises three times a day at home. In addition, the participants were regularly asked over the telephone about their performance of the exercises. Physical strength, cognitive function, and total scores of the Kihon Checklist were significantly lower after the intervention than before. In addition, the one-leg standing test time was significantly longer after the intervention (mean ± SD, 23.9 ± 35.4) than before (15.7 ± 20.5), and the sit-to-stand test time was significantly shorter after the intervention (13.0 ± 6.2) than before (14.8 ± 8.3). Locomotion training in a home-visit preventive-care program with telephone support effectively improved the motor function of elderly people who were not currently attending any preventive-care program organized by the long-term care insurance system.

  13. Atención médica ambulatoria en México: el costo para los usuarios Ambulatory medical care in Mexico: the cost for users

    Directory of Open Access Journals (Sweden)

    Armando Arredondo

    1999-01-01

    variable was the direct expense for the consumer and the independent variables, the condition of being insured and the income. Variation significance levels were identified using the test by Duncan. Results. The costs at national level in US dollar were: transport $ 2.20, medical visit $ 7.90, drugs $ 9.60, diagnostic studies $ 13.6; average total cost for ambulatory attention was $ 22.70. Empirical finding suggest a new direct and indirect cost-for-consumer analysis for the health care users. These costs represent an important burden on the family income, which worsens when users are not insured. Conclusions. Incorporation of the economic perspective to the analysis of public health issues should not be limited to the analysis of the health provider´s expenses, particulary if the problems of equity and accessibility must be solved, which are at present characteristic of health care services in Mexico.

  14. The challenge of tetradic relationships in medically interpreted pediatric primary care visits: A descriptive study of communication practices.

    Science.gov (United States)

    Pope, C A; Escobar-Gomez, M; Davis, B H; Roberts, J R; O'Brien, E S; Hinton, E; Darden, P M

    2016-04-01

    To examine spoken interactions between pediatricians and community-based interpreters speaking with adolescents and parents with Limited English proficiency (LEP) in primary care to identify the challenges of interpreting in a four-person or tetradic visit, its sources of co-constructed errors, and specific practices for educational intervention. As part of a larger study of vaccine decision-making at six clinical sites in two states, this descriptive study used discourse analysis to examine 20 routine primary care visits in a Latino Clinic in interactions between adolescents, parents, community-based interpreters, and pediatricians. Specific patterns of communication practices were identified that contributed to inaccuracies in medical interpretation Practices needing improvement were tallied for simple frequencies and included: omissions; false fluency; substitutions; editorializing; added clarification, information, or questions; medical terminology; extra explanation to mother; and, cultural additions. Of these speaking practices, omissions were the most common (123 out of 292 total) and the most affected by pediatricians. The dynamics of both pediatricians and interpreters contributed to identification of areas for improvement, with more adolescent participation in bilingual than monolingual visits. These observations provide opportunities for mapping a communication skills training intervention based on observations for future testing of an evidence-based curriculum. Published by Elsevier Ireland Ltd.

  15. A Comparison of Aromatherapy to Standard Care for Relief of PONV and PDNV in Ambulatory Surgical Patients.

    Science.gov (United States)

    Stallings-Welden, Lois M; Doerner, Mary; Ketchem, Elizabeth Libby; Benkert, Laura; Alka, Susan; Stallings, Jonathan D

    2018-04-01

    To determine effectiveness of aromatherapy (AT) compared with standard care (SC) for postoperative and postdischarge nausea and vomiting (PONV/PDNV) in ambulatory surgical patients. Prospective randomized study. Patients (n = 254) received either SC or AT for PONV and interviewed for effectiveness of PDNV. Machine learning methods (eight algorithms) were used to evaluate. Of patients (64 of 221) that experienced PONV, 52% were in the AT group and 48% in the SC group. The majority were satisfied with treatment (timely, P = .60; effectiveness, P = .86). Of patients that experienced PDNV, treatment was 100% effective in the AT group and 67% in the SC group. The cforest algorithm was used to develop a model for predicting PONV with literature-based risk factors (0.69 area under the curve). AT is an effective way to manage PONV/PDNV. Gender and age were the most important predictors of PONV. Copyright © 2016 American Society of PeriAnesthesia Nurses. All rights reserved.

  16. Hotel-based ambulatory care for complex cancer patients: a review of the University College London Hospital experience.

    Science.gov (United States)

    Sive, Jonathan; Ardeshna, Kirit M; Cheesman, Simon; le Grange, Franel; Morris, Stephen; Nicholas, Claire; Peggs, Karl; Statham, Paula; Goldstone, Anthony H

    2012-12-01

    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.

  17. Personal health record use and association with immunizations and well-child care visits recommendations.

    Science.gov (United States)

    Tom, Jeffrey O; Chen, Chuhe; Zhou, Yi Yvonne

    2014-01-01

    To determine the association of parental use of integrated personal health records (PHRs) with children's adherence to immunization and well-child care (WCC) visit recommendations. For the immunization and WCC visit measures, we retrospectively analyzed, respectively, 766 and 639 matched pairs at Kaiser Permanente (KP) Hawaii and 2795 and 2448 pairs at KP Northwest who were ≤ 31 days old at enrollment and continuously enrolled for 2 years between January 2007 and July 2011. The independent variable (≥ 1 PHR feature used vs none) was matched using propensity scores on parental and children characteristics. The dependent variables were 2 measures from the 2010 Healthcare Effectiveness Data and Information Set: combination 2 immunization (all immunizations vs immunizations only at KP Northwest (KP Hawaii: OR 1.1, 95% CI 0.8-1.4, P > .05; KP Northwest OR 1.2, 95% CI 1.0-1.3, P immunizations in only 1 region. Copyright © 2014 Mosby, Inc. All rights reserved.

  18. Injury-related visits and comorbid conditions among homeless persons presenting to emergency departments.

    Science.gov (United States)

    Hammig, Bart; Jozkowski, Kristen; Jones, Ches

    2014-04-01

    The authors examined the clinical characteristics of homeless patients presenting to emergency departments (EDs) in the United States, with a focus on unintentional and intentional injury events and related comorbid conditions. The study included a nationally representative sample of patients presenting to EDs with data obtained from the 2007 through 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS). Descriptive and analytical epidemiologic analyses were employed to examine injuries among homeless patients. Homeless persons made 603,000 visits annually to EDs, 55% of which were for injuries, with the majority related to unintentional (52%) and self-inflicted (23%) injuries. Multivariate logistic regression analyses revealed that homeless patients had a higher odds of presenting with injuries related to unintentional (odds ratio [OR]=1.4. 95% confidence interval [CI]=1.1 to 1.9), self-inflicted (OR=6.0, 95% CI=3.7 to 9.5), and assault (OR=3.0, 95% CI=1.5 to 5.9) injuries. A better understanding of the injuries affecting homeless populations may provide medical and public health professionals insight into more effective ways to intervene and limit further morbidity and mortality related to specific injury outcomes. © 2014 by the Society for Academic Emergency Medicine.

  19. [Analysis of the status and influential factors for prenatal care and postpartum visit among pregnant women based on the First Health Service Survey in Hunan Province].

    Science.gov (United States)

    Zhang, Wei; Cheng, Xunjie; Zhang, Lin; Ning, Peishan; Li, Li; Deng, Xin; Deng, Jing; Hu, Guoqing

    2016-11-28

    To evaluate the status and influential factors for prenatal care and postpartum visit among pregnant women in Hunan Province from 2008 to 2013 based on the data from the First Health Service Survey in Hunan Province.
 Methods: Based on the data of prenatal care and postpartum visit among pregnant women from the First Health Service Survey of Hunan Province in 2013, proportion of pregnant women, who didn't meet the criteria for prenatal care and postpartum visit, were calculated (≥5 times for prenatal care and ≥2 times for postpartum visit, according to the National Basic Public Health Service program, 2009 Edition). Multivariable logistic regression models were used to identify the influencial factors.
 Results: A total of 1 035 eligible women were included in data analysis. The proportion of pregnant women who did not meet the criteria were 40.12% (95% CI 24.91%-55.33%) for prenatal care and 64.88% (95% CI 39.70%-90.06%) for postpartum visit. After adjusting other confounding factors, pregnant women with middle- and high-income had lower proportions of not meeting the criteria than those with low-income, with adjusted odds ratios of 0.41 and 0.39, respectively. Multiparae had higher proportion of not meeting the criteria than primiparas, with adjusted odds ratio of 1.54, and pregnant women with age 25-34 years and 35-64 years had lower proportions of not meeting the criteria than those with age 15-24 years. In term of postpartum visit, pregnant women with middle- to high-income had lower proportions of not meeting the criteria than those with low-income, with adjusted odds ratios of 0.50, 0.46 and 0.54, respectively; multiparae had higher proportion of not meeting the criteria than primiparas, with the adjusted odds ratio of 2.30.
 Conclusion: Proportions of pregnant women of not meeting the criteria are high in Hunan Province. Local government should strengthen the management to decrease the proportions of pregnant women who do not meet the standard in

  20. Duration of a well-child visit: association with content, family-centeredness, and satisfaction.

    Science.gov (United States)

    Halfon, Neal; Stevens, Gregory D; Larson, Kandyce; Olson, Lynn M

    2011-10-01

    Studies of pediatric primary care suggest that time is an important limitation to the delivery of recommended preventive services. Given the increasingly frenetic pace of pediatric practice, there is an increased need to monitor the length of pediatric visits and the association of visit length with content, family-centered care, and parent satisfaction with care. To examine the length of well-child visits and the associations of visit length with content, family-centered care, and parent satisfaction among a national sample of children. We conducted a cross-sectional telephone survey of parents of children aged 4 to 35 months from the 2000 National Survey of Early Childhood Health (n = 2068). One-third (33.6%) of parents reported spending ≤ 10 minutes with the clinician at their last well-child visit, nearly half (47.1%) spent 11 to 20 minutes, and 20.3% spent >20 minutes. Longer visits were associated with more anticipatory guidance, more psychosocial risk assessment, and higher family-centered care ratings. A visit of >20 minutes was associated with 2.4 (confidence interval [CI]: 1.5-3.7) higher odds of receiving a developmental assessment, 3.2 (CI: 1.7-6.1) higher odds of recommending the clinician, and 9.7 (CI: 3.5-26.5) higher odds of having enough time to ask questions. Many well-child visits are of short duration, and shorter visits are associated with reductions in content and quality of care and parent satisfaction with care. Efforts to improve preventive services will require strategies that address the time devoted to well-child care. The results of this study should be interpreted in light of changes in practice standards, reimbursement, and outcome measurement that have taken place since 2000 and the limitations of the measurement of utilization solely on the basis of parent report.

  1. The Changing Impact of Gastroesophageal Reflux Disease in Clinical Practice.

    Science.gov (United States)

    Akst, Lee M; Haque, Omar J; Clarke, John O; Hillel, Alexander T; Best, Simon R A; Altman, Kenneth W

    2017-03-01

    The National Ambulatory Medical Care Survey (NAMCS) database was utilized to understand evolving national trends in diagnosis and management of reflux. The NAMCS database was queried for visits related to gastroesophageal reflux diagnosis and management. Analysis performed for time periods 1998-2001, 2002-2005, and 2006-2009 was weighted to provide national estimates of care. Results were compared to previously reported time periods from 1990 to 2001 to evaluate patterns in overall visits, age and ethnicity of patients, provider type, and prescriptions provided. The number of ambulatory visits for reflux increased from 8 684 000 in 1998-2001 to 15 750 000 in 2006-2009. Visits increased across each time period for internal medicine, family, and gastroenterology physicians. Among otolaryngologists, absolute visits increased from 1998-2001 to 2002-2005 but decreased in 2006-2009; difference between these time periods did not reach statistical significance. From 1998-2001 to 2006-2009, reflux medication use increased 233%, with continuing trends toward increased proton pump inhibitor use. Reflux visits have increased across all demographic subgroups studied. Knowledge of these trends may inform further paradigm shifts in diagnosis and management of reflux.

  2. Psychometric properties of the Persian version of the Ambulatory Care Learning Educational Environment Measure (ACLEEM questionnaire, Shiraz, Iran

    Directory of Open Access Journals (Sweden)

    Parvizi MM

    2016-09-01

    Full Text Available Mohammad Mahdi Parvizi,1,2 Mitra Amini,2 Mohammad Reza Dehghani,2 Peyman Jafari,3 Zahra Parvizi,1 1Health Policy Research Center, 2Quality Improvement in Clinical Education Research Center, 3Department of Biostatistics, Shiraz University of Medical Sciences, Shiraz, Fars, Iran Purpose: Evaluation is the main component in design and implementation of educational activities and rapid growth of educational institution programs. Outpatient medical education and clinical training environment is one of the most important parts of training of medical residents. This study aimed to determine the validity and reliability of the Persian version of Ambulatory Care Learning Educational Environment Measure (ACLEEM questionnaire, as an instrument for assessment of educational environments in residency medical clinics. Materials and methods: This study was performed on 180 residents in Shiraz University of Medical Sciences, Shiraz, Iran, in 2014–2015. The questionnaire designers’ electronic permission (by email and the residents’ verbal consent were obtained before distributing the questionnaires. The study data were gathered using ACLEEM questionnaire developed by Arnoldo Riquelme in 2013. The data were analyzed using the SPSS statistical software, version 14, and MedCalc® software. Then, the construct validity, including convergent and discriminant validities, of the Persian version of ACLEEM questionnaire was assessed. Its internal consistency was also checked by Cronbach’s alpha coefficient. Results: Five team members who were experts in medical education were consulted to test the cultural adaptation, linguistic equivalency, and content validity of the Persian version of the questionnaire. Content validity indexes were >0.9 in all items. In factor analysis of the instrument, the ­Kaiser–Meyer–Olkin index was 0.928 and Barlett’s sphericity test yielded the following results: X 2=6,717.551, df =1,225, and P ≤0.001. Besides, Cronbach

  3. Direct and indirect patient costs of dermatology clinic visits and their impact on access to care and provider preference.

    Science.gov (United States)

    Rothstein, Brooke E; Gonzalez, Jessica; Cunningham, Kiera; Saraiya, Ami; Dornelles, Adriana C; Nguyen, Bichchau M

    2017-12-01

    The direct and indirect costs of dermatology clinic visits are infrequently quantified. Indirect costs, such as the time spent traveling to and from appointments and the value of lost earnings from time away from work, are substantial costs that often are not included in economic analyses but may pose barriers to receiving care. Due to the national shortage of dermatologists, patients may have to wait longer for appointments or travel further to see dermatologists outside of their local community, resulting in high time and travel costs for patients. Patients' lost time and earnings comprise the opportunity cost of obtaining care. A monetary value for this opportunity cost can be calculated by multiplying a patient's hourly wage by the number of hours that the patient dedicated to attending the dermatology appointment. Using a single institution survey, this study quantified the direct and indirect patient costs, including opportunity costs and time burden, associated with dermatology clinic visits to better appreciate the impact of these factors on health care access and dermatologic provider preference.

  4. Development of quality metrics for ambulatory pediatric cardiology: Transposition of the great arteries after arterial switch operation.

    Science.gov (United States)

    Baker-Smith, Carissa M; Carlson, Karina; Ettedgui, Jose; Tsuda, Takeshi; Jayakumar, K Anitha; Park, Matthew; Tede, Nikola; Uzark, Karen; Fleishman, Craig; Connuck, David; Likes, Maggie; Penny, Daniel J

    2018-01-01

    To develop quality metrics (QMs) for the ambulatory care of patients with transposition of the great arteries following arterial switch operation (TGA/ASO). Under the auspices of the American College of Cardiology Adult Congenital and Pediatric Cardiology (ACPC) Steering committee, the TGA/ASO team generated candidate QMs related to TGA/ASO ambulatory care. Candidate QMs were submitted to the ACPC Steering Committee and were reviewed for validity and feasibility using individual expert panel member scoring according to the RAND-UCLA methodology. QMs were then made available for review by the entire ACC ACPC during an "open comment period." Final approval of each QM was provided by a vote of the ACC ACPC Council. Patients with TGA who had undergone an ASO were included. Patients with complex transposition were excluded. Twelve candidate QMs were generated. Seven metrics passed the RAND-UCLA process. Four passed the "open comment period" and were ultimately approved by the Council. These included: (1) at least 1 echocardiogram performed during the first year of life reporting on the function, aortic dimension, degree of neoaortic valve insufficiency, the patency of the systemic and pulmonary outflows, the patency of the branch pulmonary arteries and coronary arteries, (2) neurodevelopmental (ND) assessment after ASO; (3) lipid profile by age 11 years; and (4) documentation of a transition of care plan to an adult congenital heart disease (CHD) provider by 18 years of age. Application of the RAND-UCLA methodology and linkage of this methodology to the ACPC approval process led to successful generation of 4 QMs relevant to the care of TGA/ASO pediatric patients in the ambulatory setting. These metrics have now been incorporated into the ACPC Quality Network providing guidance for the care of TGA/ASO patients across 30 CHD centers. © 2017 Wiley Periodicals, Inc.

  5. Ambulatory anaesthesia and cognitive dysfunction

    DEFF Research Database (Denmark)

    Rasmussen, Lars S; Steinmetz, Jacob

    2015-01-01

    serious adverse outcomes, hence difficult to obtain sound scientific evidence for avoiding complications. RECENT FINDINGS: Few studies have assessed recovery of cognitive function after ambulatory surgery, but it seems that both propofol and modern volatile anaesthetics are rational choices for general...... anaesthesia in the outpatient setting. Cognitive complications such as delirium and postoperative cognitive dysfunction are less frequent in ambulatory surgery than with hospitalization. SUMMARY: The elderly are especially susceptible to adverse effects of the hospital environment such as immobilisation...

  6. Association between Health Care Utilization with Asthma Control Levels among a Sample of Adult Patients in Puerto Rico.

    Science.gov (United States)

    Marín-Centeno, Heriberto A; Ramos-Valencia, Gilberto; Rodríguez-Sánchez, Mario; González-Gavillán, Jesús; Díaz-Toro, Elba C; Torres-Cintrón, Mariela

    2016-06-01

    Asthma is an important and serious public health problem in Puerto Rico; however, very few studies measuring the association between health care utilization and asthma control levels in adult asthma patients in Puerto Rico have been done. This study is secondary analysis of an observational and cross-sectional database generated by the Latin American Asthma Insights and Management (LA AIM) survey. Our sub-sample consisted of adults 18 years or older living with asthma, representing a total of 343 individuals. This study determined the numbers of ambulatory physician visits, emergency visits to a physician or an emergency room, and hospitalizations that took place the 12 months prior to the survey. Patients were characterized as having well-controlled, partly controlled, or uncontrolled asthma. Descriptive and inferential statistics were performed to detect differences in the mean and number of events for physician visits, emergency visits, and hospitalizations by asthma control groups. After adjusting for age, sex, and chronic health conditions (other than asthma), adult asthma patients with controlled asthma had 92.0% fewer physician visits, 82.5% fewer emergency visits, and 92.2% fewer hospitalizations than did those with uncontrolled asthma. Interventions geared toward controlling asthma symptoms and clinical manifestations in adults asthma patients-which interventions might include strategies for controlling environmental risk factors, increasing patient and family education with regard to asthma management, and boosting the use of appropriate and effective medications-may have significant potential in terms of reducing the direct and indirect costs of asthma, costs that have a critical impact on the whole health care system.

  7. Varicella-related Primary Health-care Visits, Hospitalizations and Mortality in Norway, 2008-2014.

    Science.gov (United States)

    Mirinaviciute, Grazina; Kristensen, Erle; Nakstad, Britt; Flem, Elmira

    2017-11-01

    Norway does not currently implement universal varicella vaccination in childhood. We aimed to characterize health care burden of varicella in Norway in the prevaccine era. We linked individual patient data from different national registries to examine varicella vaccinations and varicella-coded primary care consultations, hospitalizations, outpatient hospital visits, deaths and viral infections of central nervous system in the whole population of Norway during 2008-2014. We estimated health care contact rates and described the epidemiology of medically attended varicella infection. Each year approximately 14,600 varicella-related contacts occurred within primary health care and hospital sector in Norway. The annual contact rate was 221 cases per 100,000 population in primary health care and 7.3 cases per 100,000 in hospital care. Both in primary and hospital care, the highest incidences were observed among children 1 year of age: 2,654 and 78.1 cases per 100,000, respectively. The annual varicella mortality was estimated at 0.06 deaths per 100,000 and in-hospital case-fatality rate at 0.3%. Very few (0.2-0.5%) patients were vaccinated against varicella. Among hospitalized varicella patients, 22% had predisposing conditions, 9% had severe-to-very severe comorbidities and 5.5% were immunocompromised. Varicella-related complications were reported in 29.3% of hospitalized patients. Varicella zoster virus was the third most frequent virus found among 16% of patients with confirmed viral infections of central nervous system. Varicella causes a considerable health care burden in Norway, especially among children. To inform the policy decision on the use of varicella vaccination, a health economic assessment of vaccination and mathematical modeling of vaccination impact are needed.

  8. Ambulatory ST segment monitoring after myocardial infarction

    DEFF Research Database (Denmark)

    Mickley, H

    1994-01-01

    as important reasons for the inconsistent findings. The precise role of ambulatory ST segment monitoring in clinical practice has yet to be established. Direct comparisons with exercise stress testing may not be appropriate for two reasons. Firstly, the main advantage of ambulatory monitoring may...

  9. Special report. Twin Cities hospital breaks down ambulatory care, overcomes fears of outpatient care.

    Science.gov (United States)

    1995-01-06

    With payers pushing for shorter hospital stays and outpatient services generating growing shares of hospitals' revenues, experts everywhere are projecting the end of the traditional inpatient-oriented hospital. Those predictions have triggered a scramble by many hospital managers to adapt their organizations and empty beds to the expected predominance of same-day services. One Minnesota facility that surveyed the outpatient trend, however, found that its strategic options weren't limited to becoming a jumbo-sized outpatient clinic, explain David Allen, a partner with The Chancellor Group, Bloomington, Minn., and Daniel Weber, vice president of Fairview Southdale Hospital, Edina, Minn., in this special report. By understanding the multidimensional nature of ambulatory services and focusing its efforts on becoming a regional hub of healthcare services, Fairview Southdale has carved its own niche in a changing provider market.

  10. Differences in treatment patterns among patients with castration-resistant prostate cancer treated by oncologists versus urologists in a US managed care population

    International Nuclear Information System (INIS)

    Engel-Nitz, Nicole M; Alemayehu, Berhanu; Parry, David; Nathan, Faith

    2011-01-01

    Differences in treatment patterns, health care resource utilization, and costs between patients with castration-resistant prostate cancer (CRPC) treated by oncologists and those treated by urologists were examined. Patients aged ≥40 with CRPC were identified using claims from a large US managed health care plan between July 2001 and December 2007. A 6-month baseline period was used to assess patient characteristics. Patients with visits to an urologist, without visits to an oncologist, were assigned to the urology cohort, and patients with visits to an oncologist, with or without visits to an urologist, were assigned to the oncology cohort. Treatment patterns, health care resource utilization, and costs during a variable follow-up period were compared between cohorts using descriptive statistics and Lin’s regression. The urology cohort had fewer comorbid illnesses (P < 0.001) and patients were less likely to have other cancers during baseline (P < 0.001) or to die during follow-up (P = 0.004) compared with the oncology cohort. The oncology cohort patients were significantly more likely to have a claim for hormones (74.5% vs 61.1%; P < 0.001), chemotherapy (46.9% vs 10.2%, P < 0.001), and radiation (22.3% vs 3.7%, P < 0.0001) over follow-up. Mean unadjusted health care costs were higher in the oncology vs the urology cohort (US$31,896 vs US$15,318, respectively; P < 0.001). At 6 years follow-up, cumulative adjusted CRPC-specific costs were significantly higher among patients treated by oncologists with chemotherapy than among patients treated by urologists. CRPC patients treated by oncologists had greater use of hormones, chemotherapy, and radiation; higher percentages of patients with inpatient stays, emergency room, and ambulatory visits; and higher health care costs, than patients treated by urologists

  11. Specialist participation in healthcare delivery transformation: influence of patient self-referral.

    Science.gov (United States)

    Aliu, Oluseyi; Sun, Gordon; Burke, James; Chung, Kevin C; Davis, Matthew M

    2014-01-01

    Improving coordination of care and containing healthcare costs are prominent goals of healthcare reform. Specialist involvement in healthcare delivery transformation efforts like Accountable Care Organizations (ACOs) is necessary to achieve these goals. However, patients’ self-referrals to specialists may undermine care coordination and incur unnecessary costs if patients frequently receive care from specialists not engaged in such healthcare delivery transformation efforts. Additionally, frequent self-referrals may also diminish the incentive for specialist participation in reform endeavors like ACOs to get access to a referral base. To examine recent national trends in self-referred new visits to specialists. A descriptive cross-sectional study of new ambulatory visits to specialists from 2000 to 2009 using data from the National Ambulatory Medical Care Survey. We calculated nationally representative estimates of the proportion of new specialist visits through self-referrals among Medicare and private insurance beneficiaries. We also estimated the nationally representative absolute number of self-referred new specialist visits among both groups of beneficiaries. Among Medicare and private insurance beneficiaries, self-referred visits declined from 32.2% (95% confidence interval [CI], 24.0%-40.4%) to 19.6% (95% CI, 13.9%-23.3%) and from 32.4% (95% CI, 27.9%-36.8%) to 24.1% (95% CI,18.8%-29.4%), respectively. Hence, at least 1 in 5 and 1 in 4 new visits to specialists among Medicare and private insurance beneficiaries, respectively, are self-referred. The current considerable rate of self-referred new specialist visits among both Medicare and private insurance beneficiaries may have adverse implications for organizations attempting to transform healthcare delivery with improved care coordination.

  12. Biomedical Wireless Ambulatory Crew Monitor

    Science.gov (United States)

    Chmiel, Alan; Humphreys, Brad

    2009-01-01

    A compact, ambulatory biometric data acquisition system has been developed for space and commercial terrestrial use. BioWATCH (Bio medical Wireless and Ambulatory Telemetry for Crew Health) acquires signals from biomedical sensors using acquisition modules attached to a common data and power bus. Several slots allow the user to configure the unit by inserting sensor-specific modules. The data are then sent real-time from the unit over any commercially implemented wireless network including 802.11b/g, WCDMA, 3G. This system has a distributed computing hierarchy and has a common data controller on each sensor module. This allows for the modularity of the device along with the tailored ability to control the cards using a relatively small master processor. The distributed nature of this system affords the modularity, size, and power consumption that betters the current state of the art in medical ambulatory data acquisition. A new company was created to market this technology.

  13. Air pollution and emergency department visits for conjunctivitis: A case-crossover study

    Directory of Open Access Journals (Sweden)

    Mieczysław Szyszkowicz

    2016-06-01

    Full Text Available Objectives: The purpose of this study was to examine the associations between emergency department (ED visits for conjunctivitis and ambient air pollution levels in urban regions across the province of Ontario, Canada. Material and Methods: Information from the National Ambulatory Care Reporting System was used to create time-series records, for the period of April 2004 to December 2011, on emergency department visits of patients suffering from conjunctivitis. A total of 77 439 emergency department visits for conjunctivitis were analyzed. A time-stratified case-crossover design was applied, completed with meta-analysis in order to pool inter-city results. Odds ratio (OR for an emergency department visit was calculated in different population strata per one-unit increase (one interquartile range – IQR increase in a pollutant’s daily level while controlling for the impacts of temperature and relative humidity. Results: Statistically significant positive results were observed in the female population sample, for nitrogen dioxide (NO2 exposure lagged 5–8 days, with the highest result for the 7-day lag (OR = 1.035, 95% CI: 1.018–1.052 and for fine particulate matter with a median aerodynamic diameter of less than 2.5 μm (PM2.5, for lags 6 and 7 days, with the highest result for lag 7 (OR = 1.017, 95% CI: 1.003–1.031. In the male population sample, statistically significant positive results were observed for NO2 at lag 5 days (OR = 1.024, 95% CI: 1.004–1.045 and for ozone (O3, at lags 0–3 and 7 days, with the highest result for lag 0 (OR = 1.038, 95% CI: 1.012–1.056. Also for males, statistically significant results were observed in the case of PM2.5 exposure lagged by 5 days (OR = 1.003, 95% CI: 1.000–1.038 and sulfur dioxide (SO2 exposure lagged by 1 and 2 days (OR = 1.016, 95% CI: 1.000–1.031 and OR = 1.018, 95% CI: 1.002–1.033. Conclusions: The findings of this study suggest that there are associations between levels of air

  14. Home care and short-run nursing homes: organizational aspects of their integration with oncological organizations.

    Science.gov (United States)

    Zavaroni, C

    2001-09-01

    Social-health care to oncological elderly patients implies interconnection among oncological hospital and sub-district services and acknowledgement of a sole access channel. The project requires the formation of an inter-administrative coordination group and of functional transmural units with evaluational and operative roles. Various care levels (protected hospital admission and discharge, continuity visits, evaluational-therapeutic integration during treatment, palliative cures) implicate specific criterion of eligibility and actions to rationalize organization, coordination and distribution of interventions. Efficiency and effectiveness depend on integration with the services that supply material and with the diagnostic and ambulatory ones. The mid-term prospectives of the integration regard computerization of diagnostic, therapeutic, care and rehabilitation courses of patients (Regional Computerized Register of Disability) and formation of polyfunctional centres that concern home, residential and hospital intervention. Powerful technological instruments and the new organizational forms now available should encourage the formation of a morally upright society.

  15. Propensity for paying home visits among general practitioners and the associations with cancer patients' place of care and death

    DEFF Research Database (Denmark)

    Winthereik, Anna K; Hjertholm, Peter; Neergaard, Mette Asbjoern

    2017-01-01

    BACKGROUND: Previous studies of associations between home visits by general practitioners and end-of-life care for cancer patients have been subject to confounding. AIM: To analyse associations between general practitioners' propensity to pay home visits and the likelihood of hospitalisation...... and dying out of hospital among their cancer patients. DESIGN: A national register cohort study with an ecological exposure. Standardised incidence rates of general practitioner home visits were calculated as a measure for propensity. Practices were grouped into propensity quartiles. Associations between...... propensity groups and end-of-life outcomes for cancer patients aged 40 or above were calculated. SETTING/PARTICIPANTS: Danish general practitioners and citizens aged 40 or above were included from 2003 to 2012. RESULTS: We included 2670 practices with 2,518,091 listed patients (18,364,679 person...

  16. Digital screen visits in home care services

    DEFF Research Database (Denmark)

    Zarakit, Mohamad; Nors Hansen, Louise; Evron, Lotte Orr

    2017-01-01

    with participant observation of three selected screen visits with older patients with a minority ethnic background. Analysis: thematic analysis based on a hermeneutic approach. Primarily results indicate that older patients with a minority ethnic background are screened out during the recruitment phase for digital...

  17. Patients who share transparent visit notes with others: characteristics, risks, and benefits.

    Science.gov (United States)

    Jackson, Sara L; Mejilla, Roanne; Darer, Jonathan D; Oster, Natalia V; Ralston, James D; Leveille, Suzanne G; Walker, Jan; Delbanco, Tom; Elmore, Joann G

    2014-11-12

    Inviting patients to read their primary care visit notes may improve communication and help them engage more actively in their health care. Little is known about how patients will use the opportunity to share their visit notes with family members or caregivers, or what the benefits might be. Our goal was to evaluate the characteristics of patients who reported sharing their visit notes during the course of the study, including their views on associated benefits and risks. The OpenNotes study invited patients to access their primary care providers' visit notes in Massachusetts, Pennsylvania, and Washington. Pre- and post-intervention surveys assessed patient demographics, standardized measures of patient-doctor communication, sharing of visit notes with others during the study, and specific health behaviors reflecting the potential benefits and risks of offering patients easy access to their visit notes. More than half (55.43%, 2503/4516) of the participants who reported viewing at least one visit note would like the option of letting family members or friends have their own Web access to their visit notes, and 21.70% (980/4516) reported sharing their visit notes with someone during the study year. Men, and those retired or unable to work, were significantly more likely to share visit notes, and those sharing were neither more nor less concerned about their privacy than were non-sharers. Compared to participants who did not share clinic notes, those who shared were more likely to report taking better care of themselves and taking their medications as prescribed, after adjustment for age, gender, employment status, and study site. One in five OpenNotes patients shared a visit note with someone, and those sharing Web access to their visit notes reported better adherence to self-care and medications. As health information technology systems increase patients' ability to access their medical records, facilitating access to caregivers may improve perceived health

  18. Effect of the Affordable Care Act Medicaid Expansion on Emergency Department Visits: Evidence From State-Level Emergency Department Databases.

    Science.gov (United States)

    Nikpay, Sayeh; Freedman, Seth; Levy, Helen; Buchmueller, Tom

    2017-08-01

    We assess whether the expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA) results in changes in emergency department (ED) visits or ED payer mix. We also test whether the size of the change in ED visits depends on the change in the size of the Medicaid population. Using all-capture, longitudinal, state data from the Agency for Healthcare Research and Quality's Fast Stats program, we implemented a difference-in-difference analysis, which compared changes in ED visits per capita and the share of ED visits by payer (Medicaid, uninsured, and private insurance) in 14 states that did and 11 states that did not expand Medicaid in 2014. Analyses controlled for state-level demographic and economic characteristics. We found that total ED use per 1,000 population increased by 2.5 visits more in Medicaid expansion states than in nonexpansion states after 2014 (95% confidence interval [CI] 1.1 to 3.9). Among the visit types that could be measured, increases in ED visits were largest for injury-related visits and for states with the largest changes in Medicaid enrollment. Compared with nonexpansion states, in expansion states the share of ED visits covered by Medicaid increased 8.8 percentage points (95% CI 5.0 to 12.6), whereas the uninsured share decreased by 5.3 percentage points (95% CI -1.7 to -8.9). The ACA's Medicaid expansion has resulted in changes in payer mix. Contrary to other studies of the ACA's effect on ED visits, our study found that the expansion also increased use of the ED, consistent with polls of emergency physicians. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

  19. Capacity utilization and the cost of primary care visits: Implications for the costs of scaling up health interventions

    Directory of Open Access Journals (Sweden)

    Johns Benjamin

    2008-11-01

    Full Text Available Abstract Objective A great deal of international attention has been focussed recently on how much additional funding is required to scale up health interventions to meet global targets such as the Millennium Development Goals (MDGs. Most of the cost estimates that have been made in response have assumed that unit costs of delivering services will not change as coverage increases or as more and more interventions are delivered together. This is most unlikely. The main objective of this paper is to measure the impact of patient load on the cost per visit at primary health care facilities and the extent to which this would influence estimates of the costs and financial requirements to scale up interventions. Methods Multivariate regression analysis was used to explore the determinants of variability in unit costs using data for 44 countries with a total of 984 observations. Findings Controlling for other possible determinants, we find that the cost of an outpatient visit is very sensitive to the number of patients seen by providers each day at primary care facilities. Each 1% increase in patient through-put results, on average, in a 27% reduction in the cost per visit (p Conclusion Variability in capacity utilization, therefore, need to be taken into account in cost estimates, and the paper develops a method by which this can be done.

  20. Childhood astrovirus-associated diarrhea in the ambulatory setting in a Public Hospital in Cordoba city, Argentina

    Directory of Open Access Journals (Sweden)

    Giordano Miguel O.

    2004-01-01

    Full Text Available Human astroviruses have been increasingly identified as important agents of diarrheal disease in children. However, the disease burden of astrovirus infection is still incompletely assessed. This paper reports results on the epidemiological and clinical characteristics of astrovirus-associated diarrhea, as well as the impact of astrovirus infection on the ambulatory setting at a Public Hospital in Córdoba city, Argentina. From February 2001 through January 2002, 97 randomly selected outpatient visits for diarrhea among children 0.05. According to our estimation about one out of seventy-four children in this cohort would be assisted annually for an astroviral-diarrheal episode in the Public Hospital and one out of eight diarrheal cases could be attributed to astrovirus infection. Astrovirus is a common symptomatic infection in pediatric outpatient visits in the public hospital in the study area, contributing 12.37% of the overall morbidity from diarrhea.

  1. The need to include obstetric nurses in prenatal care visits in the public health system

    Directory of Open Access Journals (Sweden)

    Selma Aparecida Lagrosa Garcia

    2010-06-01

    Full Text Available Objective: To investigate, with a qualitative approach, the role of Obstetric Nurses at the primary level of care given to women’s health as a vital component of the multidisciplinary team, which today is fundamental for providing care, prevention as well as health education and promotion, especially in programs whose activities are geared towards primary care of pregnant, parturient, and puerpera women. Methods: Brazilian laws and the determinations of Nursing Councils in reference to the activities of the obstetric nurse were researched, including the nurse’s responsibilities and limits. The bibliographic search was conducted in health-related journals, lay publications, and the Internet. Results: The conflicts between professional physicians and nurses were discussed. Conclusions: It was concluded that the activities of the nurse, conducting low-risk prenatal clinical visits in the basic healthcare network, has legal and ethical support and provides true benefit to the clients.

  2. Ambulatory Feedback System

    Science.gov (United States)

    Finger, Herbert; Weeks, Bill

    1985-01-01

    This presentation discusses instrumentation that will be used for a specific event, which we hope will carry on to future events within the Space Shuttle program. The experiment is the Autogenic Feedback Training Experiment (AFTE) scheduled for Spacelab 3, currently scheduled to be launched in November, 1984. The objectives of the AFTE are to determine the effectiveness of autogenic feedback in preventing or reducing space adaptation syndrome (SAS), to monitor and record in-flight data from the crew, to determine if prediction criteria for SAS can be established, and, finally, to develop an ambulatory instrument package to mount the crew throughout the mission. The purpose of the Ambulatory Feedback System (AFS) is to record the responses of the subject during a provocative event in space and provide a real-time feedback display to reinforce the training.

  3. Physical examinations and laboratory tests in antenatal care visits in Denmark. Do reported practice and current official guidelines concord with results of literature reviews? A nationwide study of the public scheme of shared antenatal care in general practice, centres of midwifery and hospital

    DEFF Research Database (Denmark)

    Kristensen, F B; Andersen, K V; Andersen, A M

    1995-01-01

    To analyse physical examinations and laboratory tests reported in antenatal care visits in relation to official guidelines and reviews of appropriateness.......To analyse physical examinations and laboratory tests reported in antenatal care visits in relation to official guidelines and reviews of appropriateness....

  4. Basic Risk Factors Awareness in Non-Communicable Diseases (BRAND) Study Among People Visiting Tertiary Care Centre in Mysuru, Karnataka.

    Science.gov (United States)

    Thippeswamy, Thippeswamy; Chikkegowda, Prathima

    2016-04-01

    Non Communicable Diseases (NCDs) are the major causes of mortality and morbidity globally. Awareness about NCDs and their risk factors has an important role in prevention and management strategies of these NCDs. 1) To assess the awareness of risk factors contributing to NCDs among the patients visiting tertiary care hospital in Mysuru district; 2) To compare the difference in awareness of risk factors for NCDs among the urban and rural patients with/ without NCD visiting the tertiary care hospital. A cross- sectional study was conducted in a tertiary care centre- JSS Hospital, Mysuru, Karnataka from March 2013 - August 2013. The patients visiting Medicine OPD during the period were the study subjects. The subjects were allocated into 4 groups: Urban without any NCD, Urban with atleast one NCD, rural without NCD, rural with atleast one NCD. A pretested questionnaire regarding awareness of risk factors for NCDs was used in the study and frequency and proportions were used to analyse the data. A total of 400 subjects, 100 subjects in each group were included in the study. Out of these subjects about 65% of the urban group and 42% of the rural group subjects were aware of the NCDs and their risk factors. Least awareness was observed among the rural subjects without any NCDs (35%). The awareness of risk factors of NCDs and knowledge regarding prevention of NCDs was not satisfactory. The results highlighted the need and scope for health education and interventions to improve the awareness about NCDs and their risk factors.

  5. California emergency department visit rates for medical conditions increased while visit rates for injuries fell, 2005-11.

    Science.gov (United States)

    Hsia, Renee Y; Nath, Julia B; Baker, Laurence C

    2015-04-01

    The emergency department (ED) is the source of most hospital admissions; provides care for patients with no other point of access to the health care system; receives advanced care referrals from primary care physicians; and provides surveillance data on injuries, infectious diseases, violence, and adverse drug events. Understanding the changes in the profile of disease in the ED can inform emergency services administration and planning and can provide insight into the public's health. We analyzed the trends in the diagnoses seen in California EDs from 2005 to 2011, finding that while the ED visit rate for injuries decreased by 0.7 percent, the rate of ED visits for noninjury diagnoses rose 13.4 percent. We also found a rise in symptom-related diagnoses, such as abdominal pain, along with nervous system disorders, gastrointestinal disease, and mental illness. These trends point out the increasing importance of EDs in providing care for complex medical cases, as well as the changing nature of illness in the population needing immediate medical attention. Project HOPE—The People-to-People Health Foundation, Inc.

  6. Psychometric properties of the Persian version of the Ambulatory Care Learning Educational Environment Measure (ACLEEM) questionnaire, Shiraz, Iran.

    Science.gov (United States)

    Parvizi, Mohammad Mahdi; Amini, Mitra; Dehghani, Mohammad Reza; Jafari, Peyman; Parvizi, Zahra

    2016-01-01

    Evaluation is the main component in design and implementation of educational activities and rapid growth of educational institution programs. Outpatient medical education and clinical training environment is one of the most important parts of training of medical residents. This study aimed to determine the validity and reliability of the Persian version of Ambulatory Care Learning Educational Environment Measure (ACLEEM) questionnaire, as an instrument for assessment of educational environments in residency medical clinics. This study was performed on 180 residents in Shiraz University of Medical Sciences, Shiraz, Iran, in 2014-2015. The questionnaire designers' electronic permission (by email) and the residents' verbal consent were obtained before distributing the questionnaires. The study data were gathered using ACLEEM questionnaire developed by Arnoldo Riquelme in 2013. The data were analyzed using the SPSS statistical software, version 14, and MedCalc ® software. Then, the construct validity, including convergent and discriminant validities, of the Persian version of ACLEEM questionnaire was assessed. Its internal consistency was also checked by Cronbach's alpha coefficient. Five team members who were experts in medical education were consulted to test the cultural adaptation, linguistic equivalency, and content validity of the Persian version of the questionnaire. Content validity indexes were >0.9 in all items. In factor analysis of the instrument, the Kaiser-Meyer-Olkin index was 0.928 and Barlett's sphericity test yielded the following results: X 2 =6,717.551, df =1,225, and P ≤0.001. Besides, Cronbach's alpha coefficient of ACLEEM questionnaire was 0.964. Cronbach's alpha coefficients were also >0.80 in all the three domains of the questionnaire. Overall, the Persian version of ACLEEM showed excellent convergent validity and acceptable discriminant validity, except for the clinical training domain. According to the results, the Persian version of

  7. Patterns of cancer screening in primary care from 2005 to 2010.

    Science.gov (United States)

    Martires, Kathryn J; Kurlander, David E; Minwell, Gregory J; Dahms, Eric B; Bordeaux, Jeremy S

    2014-01-15

    Cancer screening recommendations vary widely, especially for breast, prostate, and skin cancer screening. Guidelines are provided by the American Cancer Society, the US Preventive Services Task Force, and various professional organizations. The recommendations often differ with regard to age and frequency of screening. The objective of this study was to determine actual rates of screening in the primary care setting. Data from the National Ambulatory Medical Care Survey were used. Only adult visits to non-federally employed, office-based physicians for preventive care from 2005 through 2010 were examined. Prevalence rates for breast, pelvic, and rectal examinations were calculated, along with the rates for mammograms, Papanicolaou smears, and prostate-specific antigen tests. Factors associated with screening, including age, race, smoking status, and insurance type, were examined using t tests and chi-square tests. In total, 8521 visits were examined. The rates of most screening examinations and tests were stable over time. Clinical breast examinations took place significantly more than mammography was ordered (54.8% vs 34.6%; P<.001). White patients received more mammography (P=.031), skin examinations (P<.010), digital rectal examinations (P<.010), and prostate-specific antigen tests (P=.003) than patients of other races. Patients who paid with Medicare or private insurance received more screening than patients who had Medicaid or no insurance (P<.010). Current cancer screening practices in primary care vary significantly. Cancer screening may not follow evidence-based practices and may not be targeting patients considered most at risk. Racial and socioeconomic disparities are present in cancer screening in primary care. © 2013 American Cancer Society.

  8. Nurse-Driven Training Courses: Impact on Implementation of Ambulatory Blood Pressure Monitoring

    OpenAIRE

    F?lez-Carrob?, Estel; Sagarra-Ti?, Maria; Romero, Araceli; Rubio, Montserrat; Planas, Lourdes; P?rez-Lucena, Mar?a Jos?; Baiget, Montserrat; Cabista?, Cristina; F?lez, Jordi

    2013-01-01

    Background: Ambulatory blood pressure monitoring (ABPM) predicts cardiovascular risk and identifies white-coat and masked hypertension, efficacy of treatment and the circadian cycle of hypertensive patients. Objective: To analyze the effectiveness of ABPM implementation thoughtout a nurse-driven training program. Materials and Methodology: Twenty eight professionals were involved in the study carried out in the primary care center of the metropolitan area of Barcelona that serves 34,289 inhab...

  9. Communication Tools for End-of-Life Decision-Making in Ambulatory Care Settings: A Systematic Review and Meta-Analysis.

    Science.gov (United States)

    Oczkowski, Simon J; Chung, Han-Oh; Hanvey, Louise; Mbuagbaw, Lawrence; You, John J

    2016-01-01

    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. 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. 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. 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, pcare desired and care received by patients (RR 1.17, 95% CI 1.05-1.30, p = 0.004, low quality evidence, 2 RCTs). The use of structured communication tools may increase the frequency of discussions about and completion of advance directives, and concordance between

  10. Quality of private and public ambulatory health care in low and middle income countries: systematic review of comparative studies.

    Science.gov (United States)

    Berendes, Sima; Heywood, Peter; Oliver, Sandy; Garner, Paul

    2011-04-01

    In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options. We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred. Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases.

  11. Quality of private and public ambulatory health care in low and middle income countries: systematic review of comparative studies.

    Directory of Open Access Journals (Sweden)

    Sima Berendes

    2011-04-01

    Full Text Available BACKGROUND: In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options. METHODS AND FINDINGS: We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred. CONCLUSIONS: Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases.

  12. [The state of quality management implementation in ambulatory care nursing and inpatient nursing].

    Science.gov (United States)

    Farin, E; Hauer, J; Schmidt, E; Kottner, J; Jäckel, W H

    2013-02-01

    The demands being made on quality assurance and quality management in ambulatory care nursing and inpatient nursing facilities continue to grow. As opposed to health-care facilities such as hospitals and rehabilitation centres, we know of no other empirical studies addressing the current state of affairs in quality management in nursing institutions. The aim of this investigation was, by means of a questionnaire, to analyse the current (as of spring 2011) dissemination of quality management and certification in nursing facilities using a random sample as representative as possible of in- and outpatient institutions. To obtain our sample we compiled 800 inpatient and 800 outpatient facilities as a stratified random sample. Federal state, holder and, for inpatient facilities, the number of beds were used as stratification variables. 24% of the questionnaires were returned, giving us information on 188 outpatient and 220 inpatient institutions. While the distribution in the sample of outpatient institutions is equivalent to the population distribution, we observed discrepancies in the inpatient facilities sample. As they do not seem to be related to any demonstrable bias, we assume that our data are sufficiently representative. 4 of 5 of the responding facilities claim to employ their own quality management system, however the degree to which the quality management mechanisms are actually in use is an estimated 75%. Almost 90% of all the facilities have a quality management representative who often possesses specific additional qualifications. Many relevant quality management instruments (i. e., nursing standards of care, questionnaires, quality circles) are used in 75% of the responding institutions. Various factors in our data give the impression that quality management and certification efforts have made more progress in the inpatient facilities. Although 80% of the outpatient institutions claim to have a quality management system, only 32.1% of them admit to

  13. Prenatal Care: Third Trimester Visits

    Science.gov (United States)

    ... Pregnancy week by week During the third trimester, prenatal care might include vaginal exams to check the baby's position. By Mayo Clinic Staff Prenatal care is an important part of a healthy pregnancy, ...

  14. The ED use and non-urgent visits of elderly patients.

    Science.gov (United States)

    Gulacti, Umut; Lok, Ugur; Celik, Murat; Aktas, Nurettin; Polat, Haci

    2016-12-01

    To evaluate the use of the emergency department (ED) by elderly patients, their non-urgent visits and the prevalence of main disease for ED visits. This cross-sectional study was conducted on patients aged 65 years and over who visited the ED of a tertiary care university hospital in Turkey between January 2015 and January 2016 retrospectively. A total of 36,369 elderly patients who visited the ED were included in the study. The rate of ED visits by elderly patients was higher than their representation within the general population (p elderly patients visiting polyclinics was 15.8%, the rate of elderly patients visiting the ED was 24.3% (p elderly age groups (p elderly population (17.5%, CI: 17.1-17.9). The proportion of ED visits for non-urgent conditions was 23.4%. Most of the ED visits were during the non-business hours (51.1%), and they were highest in the winter season (25.9%) and in January (10.2%). The hospitalization rate was 9.4%, and 37.9% of hospitalized patients were admitted to intensive care units. The proportion of ED visits by elderly patients was higher than their representation within the general population. Elderly patients often visited the ED instead of a polyclinic. The rate of inappropriate ED use by elderly patients in this hospital was higher than in other countries.

  15. The effect of telephone follow-up after ambulatory surgery on pain management for children at home by parents

    Directory of Open Access Journals (Sweden)

    Saeedeh Almasi

    2016-07-01

    Full Text Available Since time was short hospitalization after ambulatory surgery after discharge the duty of care of children at home, and parents are responsible, their familiarity with pharmacological and nonpharmacological methods of pain relief is essential. Therefore, this study aimed to determine the effect of telephone follow-up after ambulatory surgery on pain management for children at home by their parents. In these clinical trial 68 children 6 to 12 years admitted for tonsillectomy operation with careful parent choice and block randomly divided into control and test. For experimental group, including training of pharmacological and nonpharmacological methods of pain relief and telephone follow-up was done in the first three days after discharge. Data were collected log home checklist was completed by parents. Data by SPSS version 16 and chi-square tests, t and analysis of variance with repeated measures were analyzed. The mean pain intensity scores, palliative effects of acetaminophen and the use of pain relief medication and non-drug control between the two groups was statistically significant difference (P <0.05. However, between the two groups was statistically significant difference was observed sedative effects. ambulatory surgery and follow-up training before the telephone after discharge would empower parents with children at home pain management.

  16. Prenatal Care: Second Trimester Visits

    Science.gov (United States)

    ... Pregnancy week by week During the second trimester, prenatal care includes routine lab tests and measurements of your ... too. By Mayo Clinic Staff The goal of prenatal care is to ensure that you and your baby ...

  17. Age, gender, will, and use of home-visit nursing care are critical factors in home care for malignant diseases; a retrospective study involving 346 patients in Japan

    Science.gov (United States)

    2011-01-01

    Background We aimed to clarify the factors affecting outcomes of home care for patients with malignant diseases. Methods Of 607 patients who were treated in 10 clinics specialized in home care between January and December 2007 at Chiba, Fukuoka, Iwate, Kagoshima, Tochigi and Tokyo prefectures across Japan, 346 (57%; 145 men and 201 women) had malignant diseases. We collected information on medical and social backgrounds, details of home care, and its outcomes based on their medical records. Results Median age of the patients was 77 years (range, 11-102), and 335 patients were economically self-sufficient. Their general condition was poor; advanced cancer (n = 308), performance status of 3-4 (n = 261), and dementia (n = 121). At the beginning of home care, 143 patients and 174 family members expressed their wish to die at home. All the patients received supportive treatments including fluid replacement and oxygenation. Median duration of home care was 47 days (range, 0-2,712). 224 patients died at home. For the remaining 122, home care was terminated due to complications (n = 109), change of attending physicians (n = 8), and others (n = 5). The factors which inhibited the continuity of home care were the non-use of home-visit nursing care (hazard ratio [HR] = 1.78, 95% confidence interval [CI]: 1.05-3.00, p = 0.03), the fact that the patients themselves do not wish to die at home (HR = 1.83, CI: 1.09-3.07, p = 0.02), women (HR = 1.81, CI: 1.11-2.94, p = 0.02), and age (HR = 0.98, CI: 0.97-1.00, p = 0.02). Conclusions Continuation of home care is influenced by patients' age, gender, will, and use of home-visit nursing. PMID:22044683

  18. Predicting recovery at home after Ambulatory Surgery

    Directory of Open Access Journals (Sweden)

    Ayala Guillermo

    2011-10-01

    Full Text Available Abstract The correct implementation of Ambulatory Surgery must be accompanied by an accurate monitoring of the patient post-discharge state. We fit different statistical models to predict the first hours postoperative status of a discharged patient. We will also be able to predict, for any discharged patient, the probability of needing a closer follow-up, or of having a normal progress at home. Background The status of a discharged patient is predicted during the first 48 hours after discharge by using variables routinely used in Ambulatory Surgery. The models fitted will provide the physician with an insight into the post-discharge progress. These models will provide valuable information to assist in educating the patient and their carers about what to expect after discharge as well as to improve their overall level of satisfaction. Methods A total of 922 patients from the Ambulatory Surgery Unit of the Dr. Peset University Hospital (Valencia, Spain were selected for this study. Their post-discharge status was evaluated through a phone questionnaire. We pretend to predict four variables which were self-reported via phone interviews with the discharged patient: sleep, pain, oral tolerance of fluid/food and bleeding status. A fifth variable called phone score will be built as the sum of these four ordinal variables. The number of phone interviews varies between patients, depending on the evolution. The proportional odds model was used. The predictors were age, sex, ASA status, surgical time, discharge time, type of anaesthesia, surgical specialty and ambulatory surgical incapacity (ASI. This last variable reflects, before the operation, the state of incapacity and severity of symptoms in the discharged patient. Results Age, ambulatory surgical incapacity and the surgical specialty are significant to explain the level of pain at the first call. For the first two phone calls, ambulatory surgical incapacity is significant as a predictor for all

  19. Integrating teaching into routine outpatient care: The design and evaluation of an ambulatory training concept (HeiSA).

    Science.gov (United States)

    Hundertmark, Jan; Apondo, Sandra Karina; Schultz, Jobst-Hendrik

    2018-01-01

    Background: Direct patient contact is crucial in learning important interactional and examination skills. However, medical students have limited opportunity to self-responsibly practise these skills in authentic clinical settings and typically receive insufficient feedback on their performance. We developed a novel single-session ambulatory teaching concept (Heidelberg Student Ambulatory training, "HeiSA") to prepare students more adequately for clinical-practical responsibilities. Methods: To identify challenges and target group needs, we reviewed current literature and consulted an expert group of faculty lecturers and training researchers. The resulting course concept was put into practice at the University Hospital's general-internistic outpatient department and evaluated in a pilot phase (winter term 2010, ten participants) and a main project phase (summer and winter terms 2011, 14 and 21 participants, respectively). Third and fourth-year students autonomously take a new patient's medical history and conduct a complete physical examination in one hour under supervision, followed by extensive preceptor feedback. To assess learning achievements, participants and a control group self-rated their communication and examination skills before and (participants only) after the session on six-point Likert scales (1=completely able, 6=completely unable). The preceptor also evaluated the participants' performance. Finally, all stakeholders re-evaluated the course concept. Results: HeiSA is a feasible training concept and accepted by staff members and students. It provides opportunities to practise clinical skills in a relevant, authentic learning environment with extensive feedback. Participants report improved anamnesis (0.27±0.51, p =.003) and physical examination (0.25±0.41, p =.008) skills. The preceptor evaluated students' performance to be generally high, with ratings ranging from 1.40±0.55 (item: the student does not interrupt the patient) to 2.51±0.89 (item

  20. Developments in ambulatory surgery in orthopedics in France in 2016.

    Science.gov (United States)

    Hulet, C; Rochcongar, G; Court, C

    2017-02-01

    Under the new categorization introduced by the Health Authorities, ambulatory surgery (AS) in France now accounts for 50% of procedures, taking all surgical specialties together. The replacement of full hospital admission by AS is now well established and recognized. Health-care centers have learned, in coordination with the medico-surgical and paramedical teams, how to set up AS units and the corresponding clinical pathways. There is no single model handed down from above. The authorities have encouraged these developments, partly by regulations but also by means of financial incentives. Patient eligibility and psychosocial criteria are crucial determining factors for the success of the AS strategy. The surgeons involved are strongly committed. Feedback from many orthopedic subspecialties (shoulder, foot, knee, spine, hand, large joints, emergency and pediatric surgery) testify to the rise of AS, which now accounts for 41% of all orthopedic procedures. Questions remain, however, concerning the role of the GP in the continuity of care, the role of innovation and teaching, the creation of new jobs, and the attractiveness of AS for surgeons. More than ever, it is the patient who is "ambulatory", within an organized structure in which surgical technique and pain management are well controlled. Not all patients can be eligible, but the AS concept is becoming standard, and overnight stay will become a matter for medical and surgical prescription. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

  1. HCUP State Ambulatory Surgery Databases (SASD) - Restricted Access Files

    Data.gov (United States)

    U.S. Department of Health & Human Services — The State Ambulatory Surgery Databases (SASD) contain the universe of hospital-based ambulatory surgery encounters in participating States. Some States include...

  2. Team-based care for improving hypertension management among outpatients (TBC-HTA): study protocol for a pragmatic randomized controlled trial.

    Science.gov (United States)

    Santschi, Valérie; Wuerzner, Grégoire; Chiolero, Arnaud; Burnand, Bernard; Schaller, Philippe; Cloutier, Lyne; Paradis, Gilles; Burnier, Michel

    2017-01-21

    Blood pressure (BP) is poorly controlled among a large proportion of hypertensive outpatients. Innovative models of care are therefore needed to improve BP control. The Team-Based Care for improving Hypertension management (TBC-HTA) study aims to evaluate the effect of a team-based care (TBC) interprofessional intervention, involving nurses, community pharmacists and physicians, on BP control of hypertensive outpatients compared to usual care in routine clinical practice. The TBC-HTA study is a pragmatic randomized controlled study with a 6-month follow-up which tests a TBC interprofessionnal intervention conducted among uncontrolled treated hypertensive outpatients in two ambulatory clinics and among seven nearby community pharmacies in Lausanne and Geneva, Switzerland. A total of 110 patients are being recruited and randomized to TBC (TBC: N = 55) or usual care group (UC: N = 55). Patients allocated to the TBC group receive the TBC intervention conducted by an interprofessional team, involving an ambulatory clinic nurse, a community pharmacist and a physician. A nurse and a community pharmacist meet patients every 6 weeks to measure BP, to assess lifestyle, to estimate medication adherence, and to provide education to the patient about disease, treatment and lifestyle. After each visit, the nurse and pharmacist write a summary report with recommendations related to medication adherence, lifestyle, and changes in therapy. The physician then adjusts antihypertensive therapy accordingly. Patients in the UC group receive usual routine care without sessions with a nurse and a pharmacist. The primary outcome is the difference in daytime ambulatory BP between TBC and UC patients at 6-month of follow-up. Secondary outcomes include patients' and healthcare professionals' satisfaction with the TBC intervention and BP control at 12 months (6 months after the end of the intervention). This ongoing study aims to evaluate the effect of a newly developed team

  3. Does emergency department use and post-visit physician care cluster geographically and temporally for adolescents who self-harm? A population-based 9-year retrospective cohort study from Alberta, Canada.

    Science.gov (United States)

    Rosychuk, Rhonda J; Johnson, David W; Urichuk, Liana; Dong, Kathryn; Newton, Amanda S

    2016-07-11

    Clustering of adolescent self-harming behaviours in the context of health care utilization has not been studied. We identified geographic areas with higher numbers of adolescents who (1) presented to an emergency department (ED) for self-harm, and (2) were without a physician follow-up visit for mental health within 14 days post-ED visit. We extracted a population-based cohort of adolescents aged 15-17 years (n = 3,927) with ED visits during 2002-2011 in Alberta, Canada. We defined the case as an individual with one or more ED presentations for self-harm in the fiscal year of the analysis. Crude case rates were calculated and clusters were identified using a spatial scan. The rates decreased over time for ED visits for self-harm (differences: girls -199.6/100,000; p self-harm (differences: girls -108.3/100,000; p self-harm (relative risks [RRs]: 1.58 for cluster 1, 3.54 for cluster 2) and were without a 14-day physician follow-up (RRs: 1.78 for cluster 1, 4.17 for cluster 2). In 2010/2011, clusters in the North, Edmonton, and Central zones were identified for adolescents with and without a follow-up visit within 14 days following an ED visit for self-harm (p self-harm and rates of adolescents without a 14-day physician follow-up visit following emergency care for self-harm decreased during the study period. The space-time clusters identified the areas and years where visits to the ED by adolescents for self-harm were statistically higher than expected. These clusters can be used to identify locations where adolescents are potentially not receiving follow-up and the mental health support needed after emergency-based care. The 2010/2011 geographic cluster suggests that the northern part of the province still has elevated numbers of adolescents visiting the ED for self-harm. Prospective research is needed to determine outcomes associated with adolescents who receive physician follow-up following ED-based care for self-harm compared to those who do not.

  4. Rural Bypass of Critical Access Hospitals in Iowa: Do Visiting Surgical Specialists Make a Difference?

    Science.gov (United States)

    Weigel, Paula A M; Ullrich, Fred; Ward, Marcia M

    2018-02-01

    Rural bypass for elective surgical procedures is a challenge for critical access hospitals, yet there are opportunities for rural hospitals to improve local retention of surgical candidates through alternative approaches to developing surgery lines of business. In this study we examine the effect of visiting surgical specialists on the odds of rural bypass. Discharge data from the 2011 State Inpatient Databases and State Ambulatory Surgery Databases for Iowa were linked to outreach data from the Office of Statewide Clinical Education Programs and Iowa Physician Information System to model the effect of surgeon specialist supply on rural patients' decision to bypass rural critical access hospitals. Patients in rural communities with a local general surgeon were more likely to be retained in a community than to bypass. Those in communities with visiting general surgeons were more likely to bypass, as were those in communities with visiting urologists and obstetricians. Patients in communities with visiting ophthalmologists and orthopedic surgeons were at higher odds of being retained for their elective surgeries. In addition to known patient and local hospital factors that have an influence on bypass behavior among rural patients seeking elective surgery, availability of surgeon specialists also plays an important role in whether patients bypass or not. Visiting ophthalmologists and orthopedic surgeons were associated with less bypass, as was having local general surgeons. Visiting general surgeons, urologists, and obstetricians were associated with greater odds of bypass. © 2016 National Rural Health Association.

  5. Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy

    Directory of Open Access Journals (Sweden)

    Forastiere Francesco

    2009-12-01

    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

  6. Use of mobile phone consultations during home visits by Community Health Workers for maternal and newborn care: community experiences from Masindi and Kiryandongo districts, Uganda.

    Science.gov (United States)

    Mangwi Ayiasi, Richard; Atuyambe, Lynn Muhimbuura; Kiguli, Juliet; Garimoi Orach, Christopher; Kolsteren, Patrick; Criel, Bart

    2015-06-18

    Home visits by Community Health Workers [In Uganda Community Health Workers are given the collective term of Village Health Teams (VHTs). Hereafter referred to as VHTs] is recommended to improve maternal and newborn care. We investigated perceived maternal and newborn benefits of home visits made by VHTs, combined with mobile phone consultations with professional health workers for advice. A qualitative study was conducted in Masindi and Kiryandongo districts, Uganda, in December-2013 to March-2014. Study participants were drawn from the intervention arm of a randomised community-intervention trial. In-depth interviews were conducted with 20 prenatal and 16 postnatal women who were visited by VHTs; 5 group discussions and 16 key informant interviews were held with VHTs and 10 Key Informant Interviews with professional health workers. Data were analysed using latent content analysis techniques. Majority women and VHTs contend that the intervention improved access to maternal and newborn information; reduced costs of accessing care and facilitated referral. Women, VHTs and professional health workers acknowledged that the intervention induced attitudinal change among women and VHTs towards adapting recommended maternal and newborn care practices. Mobile phone consultations between VHTs and professional health workers were considered to reinforce VHT knowledge on maternal newborn care and boosted the social status of VHTs in community. A minority of VHTs perceived the implementation of recommended maternal and newborn care practices as difficult. Some professional health workers did not approve of the transfer of promotional maternal and newborn responsibility to VHTs. For a range of reasons, a number of professional health workers were not always available on phone or at the health centre to address VHT concerns. Results suggest that home visits made by VHTs for maternal and newborn care are reasonably well accepted. Our study highlights potential benefits of

  7. Prescription and Underprescription of Clozapine in Dutch Ambulatory Care

    Directory of Open Access Journals (Sweden)

    Yvonne C. van der Zalm

    2018-06-01

    Full Text Available Purpose: To our knowledge, no study has examined in a structured way the extent of underprescription of clozapine in ambulatory patients with Non-Affective Psychotic Disorder (NAPD. In the Netherlands, psychiatric care for such patients is provided by Flexible Assertive Community Treatment (FACT teams and by early intervention teams. In 20 FACT teams and 3 early intervention teams we assessed the proportion of patients who: use clozapine (type 1 patients, previously used this drug (type 2, have an unfulfilled indication for this drug, by type of indication (type 3, or were at least markedly psychotic, but had not yet received two adequate treatments with other antipsychotic drugs (type 4. We expected to find major differences between teams. To rule out that these differences are caused by differences in severity of psychopathology, we also calculated the proportions of patients who use clozapine given an indication at any time (number of type 1 patients divided by the sum of type 1, 2, and 3 patients.Materials and methods: The nurse practitioner of each team identified the patients already on clozapine. Next, using a highly-structured decision tree, the nurse practitioner and psychiatrist assessed whether the remaining patients had an indication for this drug. Indications were treatment-resistant positive symptoms, tardive dyskinesia, aggression and suicidality. The severity of positive symptoms was determined using the Clinical Global Impression-Schizophrenia Scale (CGI-SCH.Results: In the participating FACT-teams 2,286 NAPD patients were assessed. The range among teams in proportions was: type 1: 8.8–34.7% (mean: 23.0%, type 2: 0–8.2% (mean: 3.5%, type 3: 1.7–15.6% (mean: 6.9%, type 4: 1.8–16.3% (mean: 8.6%. The range in proportions of patients using this drug given an indication was 49.0–90.9% (mean: 68.8%. These figures were lower in early intervention teams.Conclusions: The proportion of patients in FACT-teams who have an

  8. Development of Quality Metrics in Ambulatory Pediatric Cardiology.

    Science.gov (United States)

    Chowdhury, Devyani; Gurvitz, Michelle; Marelli, Ariane; Anderson, Jeffrey; Baker-Smith, Carissa; Diab, Karim A; Edwards, Thomas C; Hougen, Tom; Jedeikin, Roy; Johnson, Jonathan N; Karpawich, Peter; Lai, Wyman; Lu, Jimmy C; Mitchell, Stephanie; Newburger, Jane W; Penny, Daniel J; Portman, Michael A; Satou, Gary; Teitel, David; Villafane, Juan; Williams, Roberta; Jenkins, Kathy

    2017-02-07

    The American College of Cardiology Adult Congenital and Pediatric Cardiology (ACPC) Section had attempted to create quality metrics (QM) for ambulatory pediatric practice, but limited evidence made the process difficult. The ACPC sought to develop QMs for ambulatory pediatric cardiology practice. Five areas of interest were identified, and QMs were developed in a 2-step review process. In the first step, an expert panel, using the modified RAND-UCLA methodology, rated each QM for feasibility and validity. The second step sought input from ACPC Section members; final approval was by a vote of the ACPC Council. Work groups proposed a total of 44 QMs. Thirty-one metrics passed the RAND process and, after the open comment period, the ACPC council approved 18 metrics. The project resulted in successful development of QMs in ambulatory pediatric cardiology for a range of ambulatory domains. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

  9. Preventing infections when visiting

    Science.gov (United States)

    ... need.) When you visit a patient in the hospital, keep your hands away from your face. Cough or sneeze into a tissue or into the crease of your elbow, not into the air. References Calfee DP. Prevention and control of health care-associated infections. In: Goldman L, Schafer AI, eds. Goldman-Cecil ...

  10. Naloxone Administration in US Emergency Departments, 2000���2011

    OpenAIRE

    Frank, Joseph W.; Levy, Cari; Calcaterra, Susan L.; Hoppe, Jason A.; Binswanger, Ingrid A.

    2015-01-01

    Rates of opioid overdose and opioid-related emergency department (ED) visits have increased dramatically. Naloxone is an effective antidote to potentially fatal opioid overdose, but little is known about naloxone administration in ED settings. We examined trends and correlates of naloxone administration in ED visits nationally from 2000 to 2011. Using data from the National Hospital Ambulatory Medical Care Survey, we examined ED visits involving (1) the administration of naloxone or (2) a dia...

  11. Effects of early dental office visits on dental caries experience.

    Science.gov (United States)

    Beil, Heather; Rozier, R Gary; Preisser, John S; Stearns, Sally C; Lee, Jessica Y

    2014-10-01

    We determined the association between timing of a first dentist office visit before age 5 years and dental disease in kindergarten. We used North Carolina Medicaid claims (1999-2006) linked to state oral health surveillance data to compare caries experience for kindergarten students (2005-2006) who had a visit before age 60 months (n=11,394) to derive overall exposure effects from a zero-inflated negative binomial regression model. We repeated the analysis separately for children who had preventive and tertiary visits. Children who had a visit at age 37 to 48 and 49 to 60 months had significantly less disease than children with a visit by age 24 months (incidence rate ratio [IRR]=0.88; 95% confidence interval [CI]=0.81, 0.95; IRR=0.75; 95% CI=0.69, 0.82, respectively). Disease status did not differ between children who had a tertiary visit by age 24 months and other children. Medicaid-enrolled children in our study followed an urgent care type of utilization, and access to dental care was limited. Children at high risk for dental disease should be given priority for a preventive dental visit before age 3 years.

  12. Quality of Private and Public Ambulatory Health Care in Low and Middle Income Countries: Systematic Review of Comparative Studies

    Science.gov (United States)

    Berendes, Sima; Heywood, Peter; Oliver, Sandy; Garner, Paul

    2011-01-01

    Background In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options. Methods and Findings We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred. Conclusions Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases. Please see later in the article for the Editors' Summary PMID:21532746

  13. Health Care Marketing at Keller Army Community Hospital West Point, New York

    Science.gov (United States)

    1982-08-01

    p. 58 3 Robin S.E. MacStravic, "Market Research In Ambulatory Care," Journal of Ambulatory Care Management 4 (May, 1981), 37. 41bid. 5 "Should We... Kotler , Philip. Marketing for Nonprofit Organizations. Englewood Cliffs: Prentice-Hall, Inc., 1975. MacStravic, Robin E. Marketing Health Care. Germantown...they react to complaints, outside stimuli, or higher headquarters rather than take a proactive marketing approach to management . This study seeks to

  14. Computerized adaptive testing--ready for ambulatory monitoring?

    DEFF Research Database (Denmark)

    Rose, Matthias; Bjørner, Jakob; Fischer, Felix

    2012-01-01

    Computerized adaptive tests (CATs) have abundant theoretical advantages over established static instruments, which could improve ambulatory monitoring of patient-reported outcomes (PROs). However, an empirical demonstration of their practical benefits is warranted.......Computerized adaptive tests (CATs) have abundant theoretical advantages over established static instruments, which could improve ambulatory monitoring of patient-reported outcomes (PROs). However, an empirical demonstration of their practical benefits is warranted....

  15. Evaluation of a patient-centered after visit summary in primary care.

    Science.gov (United States)

    Federman, Alex D; Jandorf, Lina; DeLuca, Joseph; Gover, Mary; Sanchez Munoz, Angela; Chen, Li; Wolf, Michael S; Kannry, Joseph

    2018-03-06

    To test the impact of a redesigned, patient-centered after visit summary (AVS) on patients' and clinicians' ratings of and experience with the document. We conducted a difference-in-differences (DiD) evaluation of the impact of the redesigned AVS before and after its introduction in an academic primary care practice compared to a concurrent control practice. Outcomes included ratings of the features of the AVS. The intervention site had 118 and 98 patients in the pre- and post-intervention periods and the control site had 99 and 105, respectively. In adjusted DiD analysis, introduction of the patient-centered AVS in the intervention site increased patient reports that the AVS was an effective reminder for taking medications (p = .004) and of receipt of the AVS from clinicians (p = .002). However, they were more likely to perceive it as too long (p = .04). There were no significant changes in overall rating of the AVS by clinicians or their likelihood of providing it to patients. A patient-centered AVS increased the number of patients receiving it and reporting that it would help them remember to take their medications. Improvements in the patient-centeredness of the AVS may improve its usefulness as a document to support self-management in primary care. Copyright © 2018. Published by Elsevier B.V.

  16. The ED use and non-urgent visits of elderly patients

    OpenAIRE

    Gulacti, Umut; Lok, Ugur; Celik, Murat; Aktas, Nurettin; Polat, Haci

    2016-01-01

    Objective: To evaluate the use of the emergency department (ED) by elderly patients, their non-urgent visits and the prevalence of main disease for ED visits. Methods: This cross-sectional study was conducted on patients aged 65 years and over who visited the ED of a tertiary care university hospital in Turkey between January 2015 and January 2016 retrospectively. Results: A total of 36,369 elderly patients who visited the ED were included in the study. The rate of ED visits by elderly patien...

  17. Patients Who Share Transparent Visit Notes With Others: Characteristics, Risks, and Benefits

    OpenAIRE

    Jackson, Sara L; Mejilla, Roanne; Darer, Jonathan D; Oster, Natalia V; Ralston, James D; Leveille, Suzanne G; Walker, Jan; Delbanco, Tom; Elmore, Joann G

    2014-01-01

    Background Inviting patients to read their primary care visit notes may improve communication and help them engage more actively in their health care. Little is known about how patients will use the opportunity to share their visit notes with family members or caregivers, or what the benefits might be. Objective Our goal was to evaluate the characteristics of patients who reported sharing their visit notes during the course of the study, including their views on associated benefits and risks....

  18. A hospitalização por asma e a carência de acompanhamento ambulatorial Asthma-related hospitalizations and lack of outpatient follow-up treatment

    Directory of Open Access Journals (Sweden)

    Emanuel Sarinho

    2007-08-01

    . METHODS: A prospective case series study of hospitalized patients with asthma. The patients were asked to complete a questionnaire at admission in order to determine the frequency of prophylactic outpatient follow-up treatment. Patients presenting two or more attacks of asthma that were responsive to bronchodilators were classified as having asthma. RESULTS: In the intervals between asthma attacks, 67% (112/167 - data regarding 2 patients were not available of the patients had been treated only in the emergency room. Although 53.3%(89/167 - data regarding 2 patients were not provided of the patients had been referred to outpatient treatment, only 16% (27/169 had visited an outpatient asthma clinic regularly for preventive treatment, and only 13% (22/169 had used prophylactic medication. CONCLUSION: Most of the children and adolescents hospitalized with asthma had not undergone preventive outpatient follow-up treatment. Various problems related to the health care system, such as non-referral for outpatient follow-up treatment at hospital discharge, limited access to outpatient clinics, and the cost of prophylactic medication, might have contributed to the low rate of outpatient follow-up treatment in the population studied. Public health care policies that allow asthma control programs to work effectively should be implemented.

  19. Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home.

    Science.gov (United States)

    Hawes, Emily M; Lambert, Erika; Reid, Alfred; Tong, Gretchen; Gwynne, Mark

    2018-04-13

    Results of a study evaluating quality-of-care, financial, and patient satisfaction outcomes of pharmacist-conducted telehealth visits for diabetes management and warfarin monitoring are reported. A retrospective pre-post study was conducted to determine the impact of an electronic visit (e-visit) program targeting 2 groups of outpatients: adults with uncontrolled diabetes and warfarin-treated adults performing patient self-testing (PST) for monitoring of International Normalized Ratio (INR) values. A total of 36 patients participated in the e-visit program during the 2-year study period. Among warfarin-treated patients, the percentage of INR values in the desired range increased relative to preenrollment values (from 62.5% to 72.7%, p = 0.07), and the frequency of extreme INR values (values of 5.0) decreased (from 4.8% to 0.01%, p = 0.01); the margin per patient was $300 during the first year and $191 annually thereafter. In the diabetes group, a decrease from baseline in glycosylated hemoglobin values of 3.4 percentage points was observed at 5.7 months after enrollment ( p management of diabetes through e-visits, often in combination with in-person visits, generated revenue while significantly improving clinical outcomes. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

  20. Effects on health care use and associated cost of a home visiting program for older people with poor health status: a randomized clinical trial in the Netherlands.

    NARCIS (Netherlands)

    Bouman, A.; Rossum, E. van; Evers, S.; Ambergen, T.; Kempen, G.; Knipschild, P.

    2008-01-01

    BACKGROUND: Home visiting programs have been developed to improve the functional abilities of older people and subsequently to reduce the use of institutional care services. The results of trials have been inconsistent and their cost-effectiveness uncertain. Home visits for a high-risk population

  1. Chronic pain and pattern of health care utilization among Malaysian elderly population: National Health and Morbidity Survey III (NHMS III, 2006).

    Science.gov (United States)

    Mohamed Zaki, Lily R; Hairi, Noran N

    2014-12-01

    The aims of this study were to report prevalence of chronic pain and to examine whether chronic pain influence healthcare usage among elderly Malaysian population. This was a sub-population analysis of the elderly sample in the Malaysia's Third National Health and Morbidity Survey (NHMS III) 2006, a nation-wide population based survey. A subset of 4954 elderly aged 60 years and above was used in the analysis. Chronic pain, pain's interference and outcome variables of healthcare utilization (hospital admission and ambulatory care service) were all measured and determined by self-report. Prevalence of chronic pain among elderly Malaysian was 15.2% (95% CI: 14.5, 16.8). Prevalence of chronic pain increased with advancing age, and the highest prevalence was seen among the old-old group category (21.5%). Across young-old and old-old groups, chronic pain was more prevalent among females, Indian ethnicity, widows/widowers, rural residency and those with no educational background. Our study showed that chronic pain alone increased hospitalization but not visits to ambulatory facilities. Presence of chronic pain was significantly associated with the frequency of hospitalization (aIRR 1.11; 95% CI 1.02, 1.38) but not ambulatory care service. Chronic pain is a prevalent health problem among the elderly in Malaysia and is associated with higher hospitalization rate among the elderly population. This study provides insight into the distribution of chronic pain among the elderly and its relationship with the patterns of healthcare utilization. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  2. Health information technology in ambulatory care in a developing country.

    Science.gov (United States)

    Deimazar, Ghasem; Kahouei, Mehdi; Zamani, Afsane; Ganji, Zahra

    2018-02-01

    Physicians need to apply new technologies in ambulatory care. At present, with regard to the extended use of information technology in other departments in Iran it has yet to be considerably developed by physicians and clinical technicians in the health department. To determine the rate of use of health information technology in the clinics of specialist- and subspecialist physicians in Semnan city, Iran. This was a 2016 cross-sectional study conducted in physicians' offices of Semnan city in Iran. All physicians' offices in Semnan (130) were studied in this research. A researcher made and Likert-type questionnaire was designed, and consisted of two sections: the first section included demographic items and the second section consisted of four subscales (telemedicine, patient's safety, electronic patient record, and electronic communications). In order to determine the validity, the primary questionnaire was reviewed by one medical informatics- and two health information management experts from Semnan University of Medical Sciences. Utilizing the experts' suggestions, the questionnaire was rewritten and became more focused. Then the questionnaire was piloted on forty participants, randomly selected from different physicians' offices. Participants in the pilot study were excluded from the study. Cronbach's alpha was used to calculate the reliability of the instruments. Finally, SPSS version 16 was used to conduct descriptive and inferential statistics. The minimum mean related to the physicians' use of E-mail services for the purpose of communicating with the patients, the physicians' use of computer-aided diagnostics to diagnose the patients' illnesses, and the level of the physicians' access to the electronic medical record of patients in the other treatment centers were 2.01, 3.58, and 1.43 respectively. The maximum mean score was related to the physicians' use of social networks to communicate with other physicians (3.64). The study showed that the physicians

  3. Risk factors associated with visiting or not visiting the accident & emergency department after a fall.

    Science.gov (United States)

    Scheffer, Alice C; van Hensbroek, Pieter Boele; van Dijk, Nynke; Luitse, Jan S K; Goslings, Johannes C; Luigies, René H; de Rooij, Sophia E

    2013-07-26

    Little is known about the prevalence of modifiable risk factors of falling in elderly persons with a fall-history who do not visit the Accident and Emergency (A&E) Department after one or more falls. The objective of this study was to determine the prevalence of modifiable risk factors in a population that visited the A&E Department after a fall (A&E group) and in a community-dwelling population of elderly individuals with a fall history who did not visit the A&E Department after a fall (non-A&E group). Two cohorts were included in this study. The first cohort included 547 individuals 65 years and older who were visited at home by a mobile fall prevention team. The participants in this cohort had fall histories but did not visit the A&E Department after a previous fall. These participants were age- and gender-matched to persons who visited the A&E Department for care after a fall. All participants were asked to complete the CAREFALL Triage Instrument. The mean number of modifiable risk factors in patients who did not visit the A&E Department was 2.9, compared to 3.8 in the group that visited the A&E Department (pfalling, impaired vision, mood and high risk of osteoporosis were all independently associated with visiting the A&E Department. All modifiable risk factors for falling were found to be shared between community-dwelling elderly individuals with a fall history who visited the A&E Department and those who did not visit the Department, although the prevalence of these factors was somewhat lower in the A&E group. Preventive strategies aimed both at patients presenting to the A&E Department after a fall and those not presenting after a fall could perhaps reduce the number of recurrent falls, the occurrence of injury and the frequency of visits to the A&E Department.

  4. Reproducibility of blood pressure variation in older ambulatory and bedridden subjects.

    Science.gov (United States)

    Tsuchihashi, Takuya; Kawakami, Yasunobu; Imamura, Tsuyoshi; Abe, Isao

    2002-06-01

    We investigated the influence of ambulation on the reproducibility of circadian blood pressure variation in older nursing home residents. Ambulatory blood pressure monitoring was performed twice in 37 older nursing home residents. Nursing home in Japan. Subjects included 18 ambulatory nursing home residents who had no limitation on physical activity and 19 bedridden residents who did not participate in physical activity. Twenty-four-hour, daytime, and nighttime blood pressure levels and their variability. The 24-hour and daytime variability of systolic blood pressure (SBP) was significantly greater in ambulatory than in bedridden subjects, whereas nighttime variability was similar. Significant correlations in SBP averaged for the whole day, daytime, and nighttime were observed between the two examinations in ambulatory (r =.80-.83) and bedridden (r =.83-.91) subjects, but the variabilities of SBP for the whole day and during the daytime of the first measurement were correlated with those of the second measurement in bedridden (r =.67 and r =.47, respectively) but not in ambulatory (r =.39 and r =.28, respectively) subjects. Significant correlations were found between the nocturnal SBP changes at two occasions in both ambulatory (r =.50) and bedridden (r =.51) subjects, but the dipper versus nondipper profiles, defined as reduction in SBP of greater than 10% versus not, showed low reproducibility in ambulatory subjects; five ambulatory (28%) and one bedridden (5%) subjects showed divergent profiles between the two examinations. The reproducibility of blood pressure variation in nursing home residents is influenced by ambulation.

  5. The Efficacy of Lavender Aromatherapy in Reducing Preoperative Anxiety in Ambulatory Surgery Patients Undergoing Procedures in General Otolaryngology

    Science.gov (United States)

    Wotman, Michael; Levinger, Joshua; Leung, Lillian; Kallush, Aron; Mauer, Elizabeth

    2017-01-01

    Background Preoperative anxiety is a common problem in hospitals and other health care centers. This emotional state has been shown to negatively impact patient satisfaction and outcomes. Aromatherapy, the therapeutic use of essential oils extracted from aromatic plants, may offer a simple, low‐risk and cost‐effective method of managing preoperative anxiety. The purpose of this study was to evaluate the efficacy of lavender aromatherapy in reducing preoperative anxiety in ambulatory surgery patients undergoing procedures in general otolaryngology. Methods A prospective and controlled pilot study was conducted with 100 patients who were admitted to New York‐Presbyterian/Weill Cornell Medical Center for ambulatory surgery from January of 2015 to August of 2015. The subjects were allocated to two groups; the experimental group received inhalation lavender aromatherapy in the preoperative waiting area while the control group received standard nursing care. Both groups reported their anxiety with a visual analog scale (VAS) upon arriving to the preoperative waiting area and upon departure to the operating room. Results According to a Welch's two sample t‐test, the mean reduction in anxiety was statistically greater in the experimental group than the control group (p = 0.001). Conclusion Lavender aromatherapy reduced preoperative anxiety in ambulatory surgery patients. This effect was modest and possibly statistically significant. Future research is needed to confirm the clinical efficacy of lavender aromatherapy. Level of Evidence 2b PMID:29299520

  6. Treatment goals for ambulatory blood pressure and plasma lipids after stroke are often not reached

    DEFF Research Database (Denmark)

    Engberg, Aase Worså; Kofoed, Klaus

    2013-01-01

    In Danish health care, secondary prevention after stroke is currently handled mainly by general practitioners using office blood pressure (OBP) assessment of hypertension. The aim of this study was to compare the OBP approach to 24-hour assessment by ambulatory blood pressure (ABP) monitoring....... Furthermore, we aimed to record the degree of adherence to recommended therapy goals for blood pressure and plasma lipids....

  7. Comparing common reasons for inpatient and outpatient visits between commercially-insured duloxetine or pregabalin initiators with fibromyalgia

    Directory of Open Access Journals (Sweden)

    Zhao Y

    2012-10-01

    Full Text Available Yang Zhao,1 Peter Sun,2 Mark Bernauer31Eli Lilly and Company, 2Kailo Research Group, 3OptumInsight, Indianapolis, IN, USABackground: The purpose of this study was to examine the main reasons for inpatient or outpatient visits after initiating duloxetine or pregabalin.Methods: Commercially insured patients with fibromyalgia and aged 18–64 years who initiated duloxetine or pregabalin in 2006 with 12-month continuous enrollment before and after initiation were identified. Duloxetine and pregabalin cohorts with similar demographics, pre-index clinical and economic characteristics, and pre-index treatment patterns were constructed via propensity scoring stratification. Reasons for inpatient admissions, physician office visits, outpatient hospital visits, emergency room visits, and primary or specialty care visits over the 12 months post-index period were examined and compared. Logistic regression was used to assess the contribution of duloxetine versus pregabalin initiation to the most common reasons for visits, controlling for cross-cohort differences.Results: Per the study design, the duloxetine (n = 3711 and pregabalin (n = 4111 cohorts had similar demographics (mean age 51 years, 83% female and health care costs over the 12-month pre-index period. Total health care costs during the 12-month post-index period were significantly lower for duloxetine patients than for pregabalin patients ($19,378 versus $27,045, P < 0.05. Eight of the 10 most common reasons for inpatient admissions and outpatient hospital (physician office, emergency room, primary or specialty care visits were the same for both groups. Controlling for cross-cohort differences, duloxetine patients were less likely to be hospitalized due to an intervertebral disc disorder or major depressive disorder, to have a physician office visit due to nonspecific backache/other back/neck pain (NB/OB/NP disorder, or to go to specialty care due to a soft tissue, NB/OP/NP, or intervertebral disc

  8. How do patients perceive ambulatory psychiatric care and what are their needs?

    Science.gov (United States)

    Małus, Aleksandra; Galińska-Skok, Beata; Konarzewska, Beata; Szulc, Agata

    2018-03-14

    The quality of a doctor-patient relationship plays a vital role in all fields of medicine. In the case of psychiatry, this role is special as it provides the foundation for the whole therapeutic process. The aim of this study was to investigate the patient's perspective on psychiatric visits: patient's attitudes towards the psychiatrist, patient's view of the patient-psychiatrist relationship, and the patient's needs and expectations from this relationship. 615 psychiatric outpatients responded to the anonymous questionnaires connected with their attitudes towards the psychiatrist, evaluation of the doctor, and expectations from psychiatric care. The study was conducted in 10 out of 30 public centres for psychiatric care in north-eastern Poland. Generally, the patients liked and positively evaluated their psychiatrists. Patient's liking for the doctor was connected with the feeling that the doctor also liked the patient, as well as with perceiving the doctor as competent and willing to meet the patient. The longer the treatment with a particular psychiatrist and the rarer need to consult the doctor, the more positive attitude and evaluation of the doctor patients had. According to the patients, the most significant expectations were associated with both conversation with the doctor and receiving emotional support. The key phase for forming the patient-psychiatrist relationship was the first stage of cooperation in which patients created their attitudes towards the doctor without modifying them at further stages. Thus, further studies on learning and developing the ability to establish the relationship with the patient, inspiring the patient's trust and making psychiatric appointments comfortable from the first meeting, will be highly valuable.

  9. A cross-sectional study of emergency care utilization and associated costs of violent-related (assault) injuries in the United States.

    Science.gov (United States)

    Monuteaux, Michael C; Fleegler, Eric W; Lee, Lois K

    2017-11-01

    Violent-related (assault) injuries are a leading cause of death and disability in the United States. Many violent injury victims seek treatment in the emergency department (ED). Our objectives were to (1) estimate rates of violent-related injuries evaluated in United States EDs, (2) estimate linear trends in ED visits for violent-related injuries from 2000 to 2010, and (3) to determine the associated health care and work-loss costs. We examined adults 18 years and older from a nationally representative survey (the National Hospital Ambulatory Medical Care Survey) of ED visits, from 2000 to 2010. Violent injury was defined using International Classification of Diseases-9th Rev.-Clinical Modification, diagnosis and mechanism of injury codes. We calculated rates of ED visits for violent injuries. Medical and work-loss costs accrued by these injuries were calculated for 2005, inflation-adjusted to 2011 dollars using the WISQARS Cost of Injury Reports. An annual average of 1.4 million adults were treated for violent injuries in EDs from 2000 to 2010, comprising 1.6% (95% confidence interval, 1.5%-1.6%) of all US adult ED visits. Young adults (18-25 years), men, nonwhites, uninsured or publically insured patients, and those residing in high poverty urban areas were at increased risk for ED visits for violent injury. The 1-year, inflation-adjusted medical and work-loss cost of violent-inflicted injuries in adults in the United States was US $49.5 billion. Violent injuries account for over one million ED visits annually among adults, with no change in rates over the past decade. Young black men are at especially increased risk for ED visits for violent injuries. Overall, violent-related injuries resulted in substantial financial and societal costs. Epidemiological study, level III.

  10. Use of Team-Based Learning Pedagogy for Internal Medicine Ambulatory Resident Teaching.

    Science.gov (United States)

    Balwan, Sandy; Fornari, Alice; DiMarzio, Paola; Verbsky, Jennifer; Pekmezaris, Renee; Stein, Joanna; Chaudhry, Saima

    2015-12-01

    Team-based learning (TBL) is used in undergraduate medical education to facilitate higher-order content learning, promote learner engagement and collaboration, and foster positive learner attitudes. There is a paucity of data on the use of TBL in graduate medical education. Our aim was to assess resident engagement, learning, and faculty/resident satisfaction with TBL in internal medicine residency ambulatory education. Survey and nominal group technique methodologies were used to assess learner engagement and faculty/resident satisfaction. We assessed medical learning using individual (IRAT) and group (GRAT) readiness assurance tests. Residents (N = 111) involved in TBL sessions reported contributing to group discussions and actively discussing the subject material with other residents. Faculty echoed similar responses, and residents and faculty reported a preference for future teaching sessions to be offered using the TBL pedagogy. The average GRAT score was significantly higher than the average IRAT score by 22%. Feedback from our nominal group technique rank ordered the following TBL strengths by both residents and faculty: (1) interactive format, (2) content of sessions, and (3) competitive nature of sessions. We successfully implemented TBL pedagogy in the internal medicine ambulatory residency curriculum, with learning focused on the care of patients in the ambulatory setting. TBL resulted in active resident engagement, facilitated group learning, and increased satisfaction by residents and faculty. To our knowledge this is the first study that implemented a TBL program in an internal medicine residency curriculum.

  11. The burden of untreated mental disorders in KwaZulu-Natal Province – mapping the treatment gap

    Directory of Open Access Journals (Sweden)

    Jonathan K Burns

    2014-04-01

    Full Text Available Background. Low- and middle-income countries carry the major burden of mental disorders, yet owing to a significant lack of resources, they experience a ‘treatment gap’ in the range of 75 - 85%. Methods. Epidemiological data on mental disorders in South Africa, national census data and locally developed models for establishing treatment needs were used to calculate expected annual acute admissions and inpatient care, as well as expected annual ambulatory visits in KwaZulu-Natal (KZN Province, South Africa. These were compared with actual acute admission and inpatient care rates as well as actual ambulatory visits to mental health services in the province, derived from the District Health Information Systems. These comparisons allowed an estimation of the treatment gap for mental disorders in the province. Results. Approximately 956 000 adults were estimated to live with mental disorders in KZN. Only 19.8% (10 620 of expected admissions (53 623 took place during the one-year reporting period; while the total number of acute inpatient days accounted for 26.1% of the expected number. Average length of stay (ALOS for acute admissions was longer (21 days than the expected ALOS (16 days. At the recommended level of 30% coverage, ambulatory visits to mental health facilities accounted for 21% of the expected visits during the one-year period. Conclusion. In keeping with previous estimates, these results provide evidence that the ‘treatment gap’ for acute inpatient and ambulatory mental healthcare in KZN is ~80%. This rate is similar to the estimated mental health resource gap in the province, suggesting that gross inadequacies in mental health service provision translate directly into major unmet needs for those living with mental disorders.

  12. Discussing dementia-related behaviors during medical visits for people with Alzheimer's disease.

    Science.gov (United States)

    Hunsaker, Amanda E; Schmidt, Karen; Lingler, Jennifer H

    2010-05-01

    Research suggests that caregivers appreciate support from primary care physicians (PCPs) regarding dementia care; however, there remains a need for studies examining the role that PCPs play in behavior management. The purpose of this study was to quantitatively characterize the discussion on dementia-related behaviors (DRBs) during PCP visits and compare findings to an independently administered assessment of DRBs exhibited within a period of 4 weeks prior to the PCP visit. Twenty-five PCP visits of persons with dementia, in which caregivers coattended the visit, were audio-recorded and analyzed for occurrence of DRB discussion. Disruptive behaviors were reported by 80% of caregivers via independent assessment, yet discussed in 23% of medical visits. Dementia-related behavior discussion occurred in visits where caregivers independently reported significantly higher behavior frequency and behavior-related burden. Implications of findings for ways PCPs can assist the caregiver in behavior management are discussed.

  13. Ambulatory surgery with chloroprocaine spinal anesthesia: a review

    Directory of Open Access Journals (Sweden)

    Ghisi D

    2015-11-01

    Full Text Available Daniela Ghisi, Stefano Bonarelli Department of Anaesthesia and Postoperative Intensive Care, Istituto Ortopedico Rizzoli, Bologna, Italy Abstract: Spinal anesthesia is a reliable and safe technique for procedures of the lower extremities. Nevertheless, some of its characteristics may limit its use for ambulatory surgery, including delayed ambulation, risk of urinary retention, and pain after block regression. The current availability of short-acting local anesthetics has renewed interest for this technique also in the context of short- and ultra-short procedures. Chloroprocaine (CP is an amino-ester local anesthetic with a very short half-life. It was introduced and has been successfully used for spinal anesthesia since 1952. Sodium bisulfite was then added as a preservative after 1956. The drug was then abandoned in the 1980s for several reports of neurological deficits in patients receiving accidentally high doses of intrathecal CP during epidural labor analgesia. Animal studies have proven the safety of the preservative-free formulation, which has been extensively evaluated in volunteer studies as well as in clinical practice with a favorable profile in terms of both safety and efficacy. In comparison with bupivacaine, 2-chloroprocaine (2-CP showed faster offset times to end of anesthesia, unassisted ambulation, and discharge from hospital. These findings suggests that 2-CP may be a suitable alternative to low doses of long-acting local anesthetics in ambulatory surgery. Its safety profile also suggests that 2-CP could be a valid substitute for intrathecal short- and intermediate-acting local anesthetics, such as lidocaine and mepivacaine – often causes of transient neurological symptoms. In this context, literature suggests a dose ranging between 30 and 60 mg of 2-CP for procedures lasting 60 minutes or less, while 10 mg is considered the no-effect dose. The present review describes recent evidence about 2-CP as an anesthetic agent for

  14. The ED use and non-urgent visits of elderly patients

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    Umut Gulacti

    2016-12-01

    Full Text Available Objective: To evaluate the use of the emergency department (ED by elderly patients, their non-urgent visits and the prevalence of main disease for ED visits. Methods: This cross-sectional study was conducted on patients aged 65 years and over who visited the ED of a tertiary care university hospital in Turkey between January 2015 and January 2016 retrospectively. Results: A total of 36,369 elderly patients who visited the ED were included in the study. The rate of ED visits by elderly patients was higher than their representation within the general population (p < 0.001. While the rate of elderly patients visiting polyclinics was 15.8%, the rate of elderly patients visiting the ED was 24.3% (p < 0.001. For both genders, the rates of ED visits for patients between 65 and 74 years old was higher than for other elderly age groups (p < 0.001. The prevalence of upper respiratory tract infection (URTI was the highest within the elderly population (17.5%, CI: 17.1–17.9. The proportion of ED visits for non-urgent conditions was 23.4%. Most of the ED visits were during the non-business hours (51.1%, and they were highest in the winter season (25.9% and in January (10.2%. The hospitalization rate was 9.4%, and 37.9% of hospitalized patients were admitted to intensive care units. Conclusion: The proportion of ED visits by elderly patients was higher than their representation within the general population. Elderly patients often visited the ED instead of a polyclinic. The rate of inappropriate ED use by elderly patients in this hospital was higher than in other countries. Keywords: Non-urgent, Prevalence, Visit, Main disease, Elderly patient, Emergency department

  15. Sick-visit immunizations and delayed well-baby visits.

    Science.gov (United States)

    Robison, Steve G

    2013-07-01

    Giving recommended immunizations during sick visits for minor and acute illness such as acute otitis media has long been an American Academy of Pediatrics/Advisory Committee on Immunization Practice recommendation. An addition to the American Academy of Pediatrics policy in 2010 advised considering whether giving immunizations at the sick visit would discourage making up missed well-baby visits. This study quantifies the potential tradeoff between sick-visit immunizations and well-baby visits. This study was a retrospective cohort analysis with a case-control component of sick visits for acute otitis media that supplanted normal well-baby visits at age 2, 4, or 6 months. Infants were stratified for sick-visit immunization, no sick-visit immunization but quick makeup well-baby visits, or no sick-visit immunizations or quick makeup visits. Immunization rates and well-baby visit rates were assessed through 24 months of age. For 1060 study cases, no significant difference was detected in immunization rates or well-baby visits through 24 months of age between those with or without sick-visit immunizations. Thirty-nine percent of infants without a sick-visit shot failed to return for a quick makeup well-baby visit; this delayed group was significantly less likely to be up-to-date for immunizations (relative risk: 0.66) and had fewer well-baby visits (mean: 3.8) from 2 through 24 months of age compared with those with sick-visit shots (mean: 4.7). The substantial risk that infants will not return for a timely makeup well-baby visit after a sick visit should be included in any consideration of whether to delay immunizations.

  16. Emergency department visits during an Olympic gold medal television broadcast.

    Science.gov (United States)

    Redelmeier, Donald A; Vermeulen, Marian J

    2011-01-01

    Practice pattern variations are often attributed to physician decision-making with no accounting for patient preferences. To test whether a mass media television broadcast unrelated to health was associated with changes in the rate and characteristics of visits for acute emergency care. Time-series analysis of emergency department visits for any reason. Population-based sample of all patients seeking emergency care in Ontario, Canada. The broadcast day was defined as the Olympic men's gold medal ice hockey game final. The control days were defined as the 6 Sundays before and after the broadcast day. A total of 99 447 visits occurred over the 7 Sundays, of which 13 990 occurred on the broadcast day. Comparing the broadcast day with control days, we found no significant difference in the hourly rate of visits before the broadcast (544 vs 537, p = 0.41) or after the broadcast (647 vs 639, p = 0.55). In contrast, we observed a significant reduction in hourly rate of visits during the broadcast (647 vs 783, p television broadcasts can influence patient preferences and thereby lead to a decrease in emergency department visits.

  17. Home visits as part of a new care pathway (iAID) to improve quality of care and quality of life in ostomy patients: a cluster-randomized stepped-wedge trial

    NARCIS (Netherlands)

    Sier, M. F.; Oostenbroek, R. J.; Dijkgraaf, M. G. W.; Veldink, G. J.; Bemelman, W. A.; Pronk, A.; Spillenaar-Bilgen, E. J.; Kelder, W.; Hoff, C.; Ubbink, D. T.; Havenga, K.; Veltkamp, S. C.; T Dekker, J. W.; Boerma, D.; Eijsbouts, Q. A. J.; Lamme, B.; Vuylsteke, R. J. C. L. M.; Tobon Morales, R. E.; van Tets, W. F.

    2017-01-01

    Aim Morbidity in patients with an ostomy is high. A new care pathway, including perioperative home visits by enterostomal therapists, was studied to assess whether more elaborate education and closer guidance could reduce stoma-related complications and improve quality of life (QoL), at acceptable

  18. Self-reported competence, attitude and approach of physicians towards patients with dementia in ambulatory care: Results of a postal survey

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    van den Bussche Hendrik

    2008-03-01

    Full Text Available Abstract Background Caring for patients with dementia is a demanding task. Little is known as to whether physicians feel competent enough to perform this task or whether a lack of self-perceived competence influences attitudes and professional approach. Even less is known with respect to potential differences between general practitioners (GPs and specialists. The purpose of this study was to investigate the interrelationship between the self-perceived competence, attitude and professional approach of physicians in ambulatory care in Germany. A further aim was to compare GPs and specialists with regard to differences in these areas. Methods A standardised postal survey was sent to 389 GPs and 239 neurologists and psychiatrists in six metropolitan areas in Germany. The 49-item questionnaire consisted of attitudinal statements to be rated on a Likert-type scale. Return rates were 54 percent for GPs and 40 percent for specialists. Statistical methods used to analyze data included correlation analysis, cluster analysis and ordinal regression analysis. Results No differences were found between GPs and specialists with regard to their general attitude towards caring for patients with dementia. Approximately 15 percent of both disciplines showed a clearly negative attitude. Self-reported competence was strongly associated with general attitude. In particular among GPs, and less so among specialists, a strong positive association was found between self-reported competence, general attitude and professional approach (e.g. early detection, active case finding and cooperation with caregivers. Differences between GPs and specialists were smaller than expected and appear to predominantly reflect task differences within the German health care system. Conclusion Training opportunities which enable in particular GPs to enhance not only their competence but also their general attitude towards dementia care would appear to be beneficial and might carry positive

  19. Training Family Medicine Residents to Perform Home Visits: A CERA Survey.

    Science.gov (United States)

    Sairenji, Tomoko; Wilson, Stephen A; D'Amico, Frank; Peterson, Lars E

    2017-02-01

    Home visits have been shown to improve quality of care, save money, and improve outcomes. Primary care physicians are in an ideal position to provide these visits; of note, the Accreditation Council for Graduate Medical Education no longer requires home visits as a component of family medicine residency training. To investigate changes in home visit numbers and expectations, attitudes, and approaches to training among family medicine residency program directors. This research used the Council of Academic Family Medicine Educational Research Alliance (CERA) national survey of family medicine program directors in 2015. Questions addressed home visit practices, teaching and evaluation methods, common types of patient and visit categories, and barriers. There were 252 responses from 455 possible respondents, representing a response rate of 55%. At most programs, residents performed 2 to 5 home visits by graduation in both 2014 (69% of programs, 174 of 252) and 2015 (68%, 172 of 252). The vast majority (68%, 172 of 252) of program directors expect less than one-third of their graduates to provide home visits after graduation. Scheduling difficulties, lack of faculty time, and lack of resident time were the top 3 barriers to residents performing home visits. There appeared to be no decline in resident-performed home visits in family medicine residencies 1 year after they were no longer required. Family medicine program directors may recognize the value of home visits despite a lack of few formal curricula.

  20. Office blood pressure measurement alone often misclassifies treatment status in children with primary hypertension.

    Science.gov (United States)

    Samuel, Joyce P; Bell, Cynthia S; Hebert, Sean A; Varughese, Arun; Samuels, Joshua A; Tyson, Jon E

    2017-12-01

    Clinicians frequently rely on office blood pressure (BP) measurements alone to assess hypertension control, despite widespread acceptance of 24-h ambulatory blood pressure monitoring (ABPM) as the reference standard in the initial diagnosis of hypertension. This study was designed to investigate how often the hypertensive status differed between concurrent office BP versus ABPM measurements, and whether any patient-specific characteristics predict the risk for misclassification by office BP. This study evaluated 42 children with primary hypertension who underwent repeated ambulatory monitoring (190 total recordings) with concurrent office BP measurement as part of their participation in n-of-1 trials. In nearly 40% of the visits, the treatment status by office measurement was opposite to the status by ambulatory monitoring. Office BP underestimated the ambulatory hypertensive status (masked uncontrolled hypertension) in 25% of visits and overestimated ambulatory BP (white coat effect) in 14% of visits. The difference between office BP and ambulatory monitoring was consistent within patients across repeated visits. Patients whose office measurement underestimated or overestimated the ambulatory BP at the first visit were more likely to show persistent discrepancy at subsequent visits. The underuse of ambulatory monitoring in management decisions of children treated for primary hypertension may result in systematic misclassification of hypertension control.