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Sample records for ambulatory care clinics

  1. Beyond the clinic: redefining hospital ambulatory care.

    PubMed

    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

  2. Salary survey of ambulatory care clinical pharmacists.

    PubMed

    Anastasio, G D; Shaughnessy, A F

    1997-01-01

    To determine salary and selected fringe benefits of members of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy, we developed a self-administered questionnaire that surveyed demographic information, schooling and training, academic appointments, yearly salary (as of February 1, 1995), source of salary, outside income, annual raise, vacation time, financial support for continuing education, and board certification. Ninety-nine surveys were returned (return rate 46%). Respondents were mostly women (58%), their average age was 34 years (range 25-51 yrs), and they had a median of 5 years in the work force. Most respondents (67%) had residency training, whereas only 21% had fellowship experience. Board certification was reported by 46%. The median salary was $53,500 (average $55,861, range $35-90 k), with progression for academic rank. The last salary increase averaged 3.7%. Most (93%) respondents received an average of $1509 for travel. The survey represents a young work force. The salaries vary but show progression for accomplishment.

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

    PubMed

    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.

  4. Developing ambulatory care clinics: nurse practitioners as primary providers.

    PubMed

    Lamper-Linden, C; Goetz-Kulas, J; Lake, R

    1983-12-01

    While hospitals evaluate ambulatory clinics as a revenue-generating service alternative, nursing executives develop new areas for nursing practice in nurse-managed clinics. The authors describe the five-year growth of a nurse-managed ambulatory clinic providing primary health care to those aged 55 and older. The discussion explains nurse practitioner leadership and practice, and accountability between professions. The concept and structure of services and marketing strategies are elated to the people served. Financial feasibility, cost containment, and other factors demonstrate the clinic's contribution to its sponsoring hospital.

  5. Health System Consolidation and Diabetes Care Performance at Ambulatory Clinics.

    PubMed

    Crespin, Daniel J; Christianson, Jon B; McCullough, Jeffrey S; Finch, Michael D

    2016-10-01

    We addressed two questions regarding health system consolidation through the acquisition of ambulatory clinics: (1) Was increasing health system size associated with improved diabetes care performance and (2) Did the diabetes care performance of acquired clinics improve postacquisition? Six hundred sixty-one ambulatory clinics in Minnesota and bordering states that reported performance data from 2007 to 2013. We employed fixed effects regression to determine if increased health system size and being acquired improved clinics' performance. Using our regression results, we estimated the average effect of consolidation on the performance of clinics that were acquired during our study. Publicly reported performance data obtained from Minnesota Community Measurement. Acquired clinics experienced performance improvements starting in their third year postacquisition. By their fifth year postacquisition, acquired clinics had 3.6 percentage points (95 percent confidence interval: 2.0, 5.1) higher performance than if they had never been acquired. Increasing health system size was associated with slight performance improvements at the end of the study. Health systems modestly improved the diabetes care performance of their acquired clinics; however, we found little evidence that systems experienced large, system-wide performance gains by increasing their size. © Health Research and Educational Trust.

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

    PubMed

    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.

  7. Development and Qualitative Evaluation of Rural Ambulatory Care Clinical Clerkships.

    ERIC Educational Resources Information Center

    Raisch, Dennis W.; And Others

    1993-01-01

    A University of New Mexico pharmacy clerkship in Indian Health Service rural ambulatory clinics is described and its results compared with an urban hospital clerkship. Unique benefits to participants included improved skills in patient counseling and chart screening, more hands-on experience, extensive individual physician consultations, and…

  8. Tracking Patient Encounters and Clinical Skills to Determine Competency in Ambulatory Care Advanced Pharmacy Practice Experiences

    PubMed Central

    Pereira, Chrystian R.; Harris, Ila M.; Moon, Jean Y.; Westberg, Sarah M.; Kolar, Claire

    2016-01-01

    Objective. To determine if the amount of exposure to patient encounters and clinical skills correlates to student clinical competency on ambulatory care advanced pharmacy practice experiences (APPEs). Design. Students in ambulatory care APPEs tracked the number of patients encountered by medical condition and the number of patient care skills performed. At the end of the APPE, preceptors evaluated students’ competency for each medical condition and skill, referencing the Dreyfus model for skill acquisition. Assessment. Data was collected from September 2012 through August 2014. Forty-six responses from a student tracking tool were matched to preceptor ratings. Students rated as competent saw more patients and performed more skills overall. Preceptors noted minimal impact on workload. Conclusions. Increased exposure to patient encounters and skills performed had a positive association with higher Dreyfus stage, which may represent a starting point in the conversation for more thoughtful design of ambulatory care APPEs. PMID:26941440

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

    PubMed Central

    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% (p<0.001). All interns 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

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

    PubMed

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

    2015-01-01

    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. 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. 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% (p<0.001). All interns reported that the boot camp was good preparation for clinics and 97% felt that the boot camp boosted their confidence. 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.

  11. Role Model Ambulatory Care Clinical Training Site in a Community-Based Pharmacy.

    ERIC Educational Resources Information Center

    Magarian, Edward O.; And Others

    1993-01-01

    An interdisciplinary project provided ambulatory care clinical training for pharmacy and nursing students in community-based pharmacies, promoting early detection and medical follow-up of common health problems within the community. Students learned new clinical skills in patient health assessment, new diagnostic technologies, patient education…

  12. Integrated Clinical Geriatric Pharmacy Clerkship in Long Term, Acute and Ambulatory Care.

    ERIC Educational Resources Information Center

    Polo, Isabel; And Others

    1994-01-01

    A clinical geriatric pharmacy clerkship containing three separate practice areas (long-term, acute, and ambulatory care) is described. The program follows the medical education clerkship protocol, with a clinical pharmacy specialist, pharmacy practice resident, and student. Participation in medical rounds, interdisciplinary conferences, and…

  13. Role Model Ambulatory Care Clinical Training Site in a Community-Based Pharmacy.

    ERIC Educational Resources Information Center

    Magarian, Edward O.; And Others

    1993-01-01

    An interdisciplinary project provided ambulatory care clinical training for pharmacy and nursing students in community-based pharmacies, promoting early detection and medical follow-up of common health problems within the community. Students learned new clinical skills in patient health assessment, new diagnostic technologies, patient education…

  14. Integrated Clinical Geriatric Pharmacy Clerkship in Long Term, Acute and Ambulatory Care.

    ERIC Educational Resources Information Center

    Polo, Isabel; And Others

    1994-01-01

    A clinical geriatric pharmacy clerkship containing three separate practice areas (long-term, acute, and ambulatory care) is described. The program follows the medical education clerkship protocol, with a clinical pharmacy specialist, pharmacy practice resident, and student. Participation in medical rounds, interdisciplinary conferences, and…

  15. Implementation of performance metrics to assess pharmacists' activities in ambulatory care clinics.

    PubMed

    Schmidt, Lauren; Klink, Chris; Iglar, Arlene; Sharpe, Neha

    2017-01-01

    The development and implementation of performance metrics for assessing the impact of pharmacists' activities in ambulatory care clinics are described. Ambulatory care clinic pharmacists within an integrated health system were surveyed to ascertain baseline practices for documenting and tracking performance metrics. Through literature review and meetings with various stakeholders, priorities for metric development were identified; measures of care quality, financial impact, and patient experience were developed. To measure the quality of care, pharmacists' interventions at five ambulatory care clinics within the health system were assessed. Correlation of pharmacist interventions with estimated cost avoidance provided a measure of financial impact. Surveys were distributed at the end of clinic visits to measure satisfaction with the patient care experience. An electronic system for metric documentation and automated tabulation of data on quality and financial impact was built. In a 12-week pilot program conducted at three clinic sites, the metrics were used to assess pharmacists' activities. A total of 764 interventions were documented (a mean of 24 accepted recommendations per pharmacist full-time equivalent each week), resulting in estimated cost avoidance of more than $40,000; survey results indicated high patient satisfaction with the services provided by pharmacists. Biweekly report auditing and solicitation of feedback guided metric refinement and further training of pharmacists. Tools and procedures were established for future metric expansion. Development and implementation of performance metrics resulted in successful capture and characterization of pharmacists' activities and their impact on patient care in three ambulatory care clinics. Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

  16. Allocation of resources for ambulatory care -a staffing model for outpatient clinics.

    PubMed Central

    Mansdorf, B D

    1975-01-01

    The enormous commitment of resources to ambulatory health care services requires that flexible and easily implementable management techniques be developed to improve the allocation of health manpower and funds. This article develops a feasible model for staffing outpatient clinics and thereby potentially provides an important analytical tool for allocating and monitoring the utilization of the most critical and expensive of ambulatory care resources-professional and nonprofessional clinic personnel. The model is simplistic, extremely flexible, and can be applied to many modes of delivering ambulatory care-from HMOs to traditional hospital outpatient clinics. To employ the model, certain decision variables must be specified so that the model can produce a least-cost staffing configuration to meet the demand for service in accordance with the desired mode and intensity of care. The key decision varables that require input from administrators and medical personnel include standards for physician-patient contact time, a desired ratio of staff time actually spent treating patients to total paid staff time, and the desired mix of various staff categories to achieve program objectives. Specific benefits of using the model include determining staffing for new, expanded, or existing outpatient clinics, determining budget requirements for such staffing needs, and providing quantitative productivity and utilization objectives and measurements. PMID:809787

  17. Optimizing management and financial performance of the teaching ambulatory care clinic.

    PubMed

    Stahl, James E; Roberts, Mark S; Gazelle, Scott

    2003-04-01

    To examine how to optimize teaching ambulatory care clinics performance with regard to access to care, access to teaching, and financial viability. Optimization analysis using computer simulation. A discrete-event simulation model of the teaching ambulatory clinic setting was developed. This method captures flow time, waiting time, competition for resources, and the interdependency of events, providing insight into system dynamics. Sensitivity analyses were performed on staffing levels, room availability, patient characteristics such as "new" versus "established" status, and clinical complexity and pertinent probabilities. In the base-case, 4 trainees:preceptor, patient flow time (registration to check out) was 148 minutes (SD 5), wait time was 20.6 minutes (SD 4.4), the wait for precepting was 6.2 minutes (SD 1.2), and average daily net clinic income was $1,413. Utilization rates were preceptors (59%), trainees (61%), medical assistants (64%), and room (68%). Flow time and the wait times remained relatively constant for strategies with trainee:preceptor ratios <4:1 but increased with number of trainees steadily thereafter. Maximum revenue occurred with 3 preceptors and 5 trainees per preceptor. The model was relatively insensitive to the proportion of patients presenting who were new, and relatively sensitive to average evaluation and management (E/M) level. Flow and wait times rose on average by 0.05 minutes and 0.01 minutes per percent new patient, respectively. For each increase in average E/M level, flow time increased 8.4 minutes, wait time 1.2 minutes, wait for precepting 0.8 minutes, and net income increased by $490. Teaching ambulatory care clinics appear to operate optimally, minimizing flow time and waiting time while maximizing revenue, with trainee-to-preceptor ratios between 3 and 7 to 1.

  18. Optimizing Management and Financial Performance of the Teaching Ambulatory Care Clinic

    PubMed Central

    Stahl, James E; Roberts, Mark S; Gazelle, Scott

    2003-01-01

    OBJECTIVE To examine how to optimize teaching ambulatory care clinics performance with regard to access to care, access to teaching, and financial viability. DESIGN Optimization analysis using computer simulation. METHODS A discrete-event simulation model of the teaching ambulatory clinic setting was developed. This method captures flow time, waiting time, competition for resources, and the interdependency of events, providing insight into system dynamics. Sensitivity analyses were performed on staffing levels, room availability, patient characteristics such as “new” versus “established” status, and clinical complexity and pertinent probabilities. MAIN RESULTS In the base-case, 4 trainees:preceptor, patient flow time (registration to check out) was 148 minutes (SD 5), wait time was 20.6 minutes (SD 4.4), the wait for precepting was 6.2 minutes (SD 1.2), and average daily net clinic income was $1,413. Utilization rates were preceptors (59%), trainees (61%), medical assistants (64%), and room (68%). Flow time and the wait times remained relatively constant for strategies with trainee:preceptor ratios <4:1 but increased with number of trainees steadily thereafter. Maximum revenue occurred with 3 preceptors and 5 trainees per preceptor. The model was relatively insensitive to the proportion of patients presenting who were new, and relatively sensitive to average evaluation and management (E/M) level. Flow and wait times rose on average by 0.05 minutes and 0.01 minutes per percent new patient, respectively. For each increase in average E/M level, flow time increased 8.4 minutes, wait time 1.2 minutes, wait for precepting 0.8 minutes, and net income increased by $490. CONCLUSION Teaching ambulatory care clinics appear to operate optimally, minimizing flow time and waiting time while maximizing revenue, with trainee-to-preceptor ratios between 3 and 7 to 1. PMID:12709093

  19. The Role of Rural Health Clinics in Hospitalization Due to Ambulatory Care Sensitive Conditions: A Study in Nebraska

    ERIC Educational Resources Information Center

    Zhang, Wanqing; Mueller, Keith J.; Chen, Li-Wu; Conway, Kevin

    2006-01-01

    Context: Hospitalization due to ambulatory care sensitive conditions (ACSCs) is often used as an indicator for measuring access to primary care. Rural health clinics (RHCs) provide basic primary care services for rural residents in health professional shortage areas (HPSAs). The relationship between RHCs and ACSCs is unclear. Purpose: The purpose…

  20. Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics.

    PubMed

    Vahdat, Vahab; Griffin, Jacqueline; Stahl, James E

    2017-08-09

    To address prolonged lengths of stay (LOS) in ambulatory care clinics, we analyze the impact of implementing flexible and dynamic policies for assigning exam rooms to providers. In contrast to the traditional approaches of assigning specific rooms to each provider or pooling rooms among all practitioners, we characterize the impact of alternate compromise policies that have not been explored in previous studies. Since ambulatory care patients may encounter multiple different providers in a single visit, room allocation can be determined separately for each encounter accordingly. For the first phase of the visit, conducted by the medical assistant, we define a dynamic room allocation policy that adjusts room assignments based on the current state of the clinic. For the second phase of the visit, conducted by physicians, we define a series of room sharing policies which vary based on two dimensions, the number of shared rooms and the number of physicians sharing each room. Using a discrete event simulation model of an outpatient cardiovascular clinic, we analyze the benefits and costs associated with the proposed room allocation policies. Our findings show that it is not necessary to fully share rooms among providers in order to reduce patient LOS and physician idle time. Instead, most of the benefit of pooling can be achieved by implementation of a compromise room allocation approach, limiting the need for significant organizational changes within the clinic. Also, in order to achieve most of the benefits of room allocation policies, it is necessary to increase flexibility in the two dimensions simultaneously. These findings are shown to be consistent in settings with alternate patient scheduling and distinctions between physicians.

  1. Diagnosing malignant melanoma in ambulatory care: a systematic review of clinical prediction rules.

    PubMed

    Harrington, Emma; Clyne, Barbara; Wesseling, Nieneke; Sandhu, Harkiran; Armstrong, Laura; Bennett, Holly; Fahey, Tom

    2017-03-06

    Malignant melanoma has high morbidity and mortality rates. Early diagnosis improves prognosis. Clinical prediction rules (CPRs) can be used to stratify patients with symptoms of suspected malignant melanoma to improve early diagnosis. We conducted a systematic review of CPRs for melanoma diagnosis in ambulatory care. Systematic review. A comprehensive search of PubMed, EMBASE, PROSPERO, CINAHL, the Cochrane Library and SCOPUS was conducted in May 2015, using combinations of keywords and medical subject headings (MeSH) terms. Studies deriving and validating, validating or assessing the impact of a CPR for predicting melanoma diagnosis in ambulatory care were included. Data extraction and methodological quality assessment were guided by the CHARMS checklist. From 16 334 studies reviewed, 51 were included, validating the performance of 24 unique CPRs. Three impact analysis studies were identified. Five studies were set in primary care. The most commonly evaluated CPRs were the ABCD, more than one or uneven distribution of Colour, or a large (greater than 6 mm) Diameter (ABCD) dermoscopy rule (at a cut-point of >4.75; 8 studies; pooled sensitivity 0.85, 95% CI 0.73 to 0.93, specificity 0.72, 95% CI 0.65 to 0.78) and the 7-point dermoscopy checklist (at a cut-point of ≥1 recommending ruling in melanoma; 11 studies; pooled sensitivity 0.77, 95% CI 0.61 to 0.88, specificity 0.80, 95% CI 0.59 to 0.92). The methodological quality of studies varied. At their recommended cut-points, the ABCD dermoscopy rule is more useful for ruling out melanoma than the 7-point dermoscopy checklist. A focus on impact analysis will help translate melanoma risk prediction rules into useful tools for clinical practice. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

  2. Diagnosing malignant melanoma in ambulatory care: a systematic review of clinical prediction rules

    PubMed Central

    Harrington, Emma; Clyne, Barbara; Wesseling, Nieneke; Sandhu, Harkiran; Armstrong, Laura; Bennett, Holly; Fahey, Tom

    2017-01-01

    Objectives Malignant melanoma has high morbidity and mortality rates. Early diagnosis improves prognosis. Clinical prediction rules (CPRs) can be used to stratify patients with symptoms of suspected malignant melanoma to improve early diagnosis. We conducted a systematic review of CPRs for melanoma diagnosis in ambulatory care. Design Systematic review. Data sources A comprehensive search of PubMed, EMBASE, PROSPERO, CINAHL, the Cochrane Library and SCOPUS was conducted in May 2015, using combinations of keywords and medical subject headings (MeSH) terms. Study selection and data extraction Studies deriving and validating, validating or assessing the impact of a CPR for predicting melanoma diagnosis in ambulatory care were included. Data extraction and methodological quality assessment were guided by the CHARMS checklist. Results From 16 334 studies reviewed, 51 were included, validating the performance of 24 unique CPRs. Three impact analysis studies were identified. Five studies were set in primary care. The most commonly evaluated CPRs were the ABCD, more than one or uneven distribution of Colour, or a large (greater than 6 mm) Diameter (ABCD) dermoscopy rule (at a cut-point of >4.75; 8 studies; pooled sensitivity 0.85, 95% CI 0.73 to 0.93, specificity 0.72, 95% CI 0.65 to 0.78) and the 7-point dermoscopy checklist (at a cut-point of ≥1 recommending ruling in melanoma; 11 studies; pooled sensitivity 0.77, 95% CI 0.61 to 0.88, specificity 0.80, 95% CI 0.59 to 0.92). The methodological quality of studies varied. Conclusions At their recommended cut-points, the ABCD dermoscopy rule is more useful for ruling out melanoma than the 7-point dermoscopy checklist. A focus on impact analysis will help translate melanoma risk prediction rules into useful tools for clinical practice. PMID:28264830

  3. An adoption study of a clinical reminder system in ambulatory care using a developmental trajectory approach.

    PubMed

    Zheng, Kai; Padman, Rema; Johnson, Michael P; Engberg, John; Diamond, Herbert H

    2004-01-01

    In this study, we assess 41 medical residents' acceptance and adoption of a clinical reminder system for chronic disease and preventive care management in the ambulatory care environment using a novel developmental trajectory approach. This group-based, semi-parametric statistical modeling method identifies distinct groups, following distinct usage trajectories, among those who recorded use of the reminder system within an evaluation period of 10 months. We trace system use within these groups over time using computer-generated logs and user satisfaction surveys. Our preliminary analysis of this small sample of users delineates three categories of users. Feedback from these categories of users is being used to re-engineer the application and adapt it better to their workflow and functionality requirements. Despite the small sample size in this particular study, we conclude that this methodology has considerable promise to provide new insights into system usability and adoption issues that may benefit clinical decision support systems as well as information systems more generally.

  4. National Ambulatory Medical Care Survey: tobacco intervention practices in outpatient clinics.

    PubMed

    Payne, Thomas J; Chen, Chieh-I; Baker, Christine L; Shah, Sonali N; Pashos, Chris L; Boulanger, Luke

    2012-09-01

    Tobacco use remains the leading cause of preventable death. The outpatient medical clinic represents an important venue for delivering evidence-based interventions to large numbers of tobacco users. Extensive evidence supports the effectiveness of brief interventions. In a retrospective database analysis of 11,827 adult patients captured in the 2005 National Ambulatory Medical Care Survey (of which 2,420 were tobacco users), we examined the degree to which a variety of patient demographic, clinical and physician-related variables predict the delivery of tobacco counseling during a routine outpatient visit in primary care settings. In 2005, 21.7% of identified tobacco users received a tobacco intervention during their visit. The probability of receiving an intervention differed by gender, geographic region and source of payment. Individuals presenting with tobacco-related health conditions were more likely to receive an intervention. Most physicians classified as specialists were less likely to intervene. The provision of tobacco intervention services appears to be increasing at a modest rate, but remains well below desirable levels. It is a priority that brief interventions be routinely implemented to reduce the societal burden of tobacco use. PsycINFO Database Record (c) 2012 APA, all rights reserved.

  5. Process in Ambulatory Care: A Controlled Clinical Trial of Computerized Records

    PubMed Central

    Tape, Thomas G.; Seelig, Charles B.; Givner, Nathaniel; Patil, Kashinath; Wigton, Robert S.; Campbell, James R.

    1988-01-01

    We implemented a controlled study of computerized ambulatory records compared with traditional paper charts. This paper reports the effect of a computer health care maintenance reminder system on compliance with recommended preventive health care maneuvers. Medical residents who had access to computerized records and reminders did significantly more hemoccult tests, proctosigmoidoscopy and influenza vaccinations than residents using paper records. The attending physician staffing the resident also had a profound but independent effect on whether preventive care was delivered. These results show that computerized records can improve the process of medical care.

  6. Evaluation of patient perceptions and outcomes related to anticoagulation point-of-care testing in ambulatory care clinics.

    PubMed

    Thompson, Amy N; Ragucci, Kelly R; Fermo, Joli D; Whitley, Heather P

    2009-10-01

    Until recently, Prothrombin Time/International Normalized Ratio (PT/INR) measurements have typically been used to monitor patients on warfarin through institutional laboratories via venous puncture. The Point-of-Care Testing (POCT) device has revolutionized the patient care process by allowing for laboratory testing outside of the central laboratory. To analyze humanistic and clinical outcomes in patients currently treated with warfarin and monitored through a pharmacist-managed anticoagulation clinic using point-of-care testing (POCT) device versus venipuncture within ambulatory care clinics at our institution. All patients currently treated with warfarin therapy who were managed by clinical pharmacists for anticoagulation monitoring at the Medical University of South Carolina (MUSC) Family Medicine Center and University Diagnostic Center, were enrolled. Patients were asked to complete a satisfaction survey regarding their anticoagulation monitoring. In addition, data related to emergency department (ED) visits, hospitalizations and percent of time in the INR therapeutic range for 6 months pre- and post-implementation of POCT device was collected. This information was obtained through an electronic patient information database, Oacis. A total of 145 patients were included in the data collection from the two clinics. The majority (41%) of these patients were taking warfarin for atrial fibrillation. Satisfaction surveys were completed by 86 (59 %) of patients. The surveys revealed that POCT device was preferred over venipuncture in 95% of patients. Reasons for the preference included more face-to-face interaction, less wait time, less pain, less blood needed, and quicker results. Of the 145 patients who were included in the objective data analysis, no significant differences were found in the number of hospitalizations, ED visits, or percent of time in the INR therapeutic range pre- and post-implementation of POCT device. The results of this study demonstrate

  7. Validation, Revision, and Evaluation of a Clinical Experience Using Ambulatory Care Facilities as Learning Sites for Student Nurses.

    ERIC Educational Resources Information Center

    Gregory, Faye M.

    A study confirmed the need for an ambulatory nursing experience as part of the vocational nursing (VN) program at the Long Beach City College (LBCC). Information on which to base the revision of the ambulatory care (AC) experience was obtained from a literature review and interviews with the following: AC administrators, California Board of…

  8. Big Data and Ambulatory Care

    PubMed Central

    Thorpe, Jane Hyatt; Gray, Elizabeth Alexandra

    2015-01-01

    Big data is heralded as having the potential to revolutionize health care by making large amounts of data available to support care delivery, population health, and patient engagement. Critics argue that big data's transformative potential is inhibited by privacy requirements that restrict health information exchange. However, there are a variety of permissible activities involving use and disclosure of patient information that support care delivery and management. This article presents an overview of the legal framework governing health information, dispels misconceptions about privacy regulations, and highlights how ambulatory care providers in particular can maximize the utility of big data to improve care. PMID:25401945

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

    PubMed

    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.

  10. Integrating patient safety and clinical pharmacy services into the care of a high-risk, ambulatory population: a collaborative approach.

    PubMed

    Robbins, Carolyn M; Stillwell, Tracy; Johnson, Deborah; Wilson, Sally; Fitzgerald, Lynn

    2013-06-01

    Lincoln Community Health Center participated in a Health Resources and Services Administration-sponsored Patient Safety and Clinical Pharmacy Services Collaborative aimed at facilitating integration of pharmacy services proven to enhance patient safety into care provided to a high-risk, ambulatory population. The Collaborative used the Plan-Do-Study-Act (PDSA) cycle of learning from the Model for Improvement endorsed by the Institute for Healthcare Improvement to guide changes. Outcomes targeted for improvement included medication reconciliation, obesity screening and follow-up planning, adverse drug events (patient safety), and delivery of clinical pharmacy services. Primary changes that resulted from conducting 54 PDSA cycles of learning included enhanced data access, centralized medication access through formulary expansion, implemented a medication reconciliation guideline, designated a single point of accountability in the pharmacy, improved efficiency, staff performed nontraditional roles, extended the existing adverse drug event program, and improved communication. Changes made to integrate patient safety and clinical pharmacy services into the care of a high-risk, ambulatory population not only improved all targeted outcomes but also helped establish Lincoln Community Health Center as the patient's medical home.

  11. Communication in acute ambulatory care.

    PubMed

    Dean, Marleah; Oetzel, John; Sklar, David P

    2014-12-01

    Effective communication has been linked to better health outcomes, higher patient satisfaction, and treatment adherence. Communication in ambulatory care contexts is even more crucial, as providers typically do not know patients' medical histories or have established relationships, conversations are time constrained, interruptions are frequent, and the seriousness of patients' medical conditions may create additional tension during interactions. Yet, health communication often unduly emphasizes information exchange-the transmission and receipt of messages leading to a mutual understanding of a patient's condition, needs, and treatments. This approach does not take into account the importance of rapport building and contextual issues, and may ultimately limit the amount of information exchanged.The authors share the perspective of communication scientists to enrich the current approach to medical communication in ambulatory health care contexts, broadening the under standing of medical communication beyond information exchange to a more holistic, multilayered viewpoint, which includes rapport and contextual issues. The authors propose a socio-ecological model for understanding communication in acute ambulatory care. This model recognizes the relationship of individuals to their environment and emphasizes the importance of individual and contextual factors that influence patient-provider interactions. Its key elements include message exchange and individual, organizational, societal, and cultural factors. Using this model, and following the authors' recommendations, providers and medical educators can treat communication as a holistic process shaped by multiple layers. This is a step toward being able to negotiate conflicting demands, resolve tensions, and create encounters that lead to positive health outcomes.

  12. Improving year-end transfers of care in academic ambulatory clinics: a survey of pediatric resident physician perceptions.

    PubMed

    Lerner, Carlos F; Hamilton, Leslie J; Klitzner, Thomas S

    2012-01-01

    In resident primary care continuity clinics, at the end of each academic year, continuity of care is disrupted when patients cared for by the graduating class are redistributed to other residents. Yet, despite the recent focus on the transfers of care between resident physicians in inpatient settings, there has been minimal attention given to patient care transfers in academic ambulatory clinics. We sought to elicit the views of pediatric residents regarding year-end patient handoffs in a pediatric resident continuity clinic. Residents assigned to a continuity clinic of a large pediatric residency program completed a questionnaire regarding year-end transfers of care. Thirty-one questionnaires were completed out of a total 45 eligible residents (69% response). Eighty seven percent of residents strongly or somewhat agreed that it would be useful to receive a written sign-out for patients with complex medical or social issues, but only 35% felt it would be useful for patients with no significant issues. Residents more frequently reported having access to adequate information regarding their new patients' medical summary (53%) and care plan (47%) than patients' functional abilities (30%), social history (17%), or use of community resources (17%). When rating the importance of receiving adequate sign-out in each those domains, residents gave most importance to the medical summary (87% of residents indicating very or somewhat important) and plan of care (84%). Residents gave less importance to receiving sign-out regarding their patients' functional abilities (71%) social history (58%), and community resources (58%). Residents indicated that lack of access to adequate patient information resulted in additional work (80%), delays or omissions in needed care (56%), and disruptions in continuity of care (58%). In a single-site study, residents perceive that they lack adequate information during year-end patient transfers, resulting in potential negative consequences for

  13. Improving year-end transfers of care in academic ambulatory clinics: a survey of pediatric resident physician perceptions

    PubMed Central

    Lerner, Carlos F.; Hamilton, Leslie J.; Klitzner, Thomas S.

    2012-01-01

    Background In resident primary care continuity clinics, at the end of each academic year, continuity of care is disrupted when patients cared for by the graduating class are redistributed to other residents. Yet, despite the recent focus on the transfers of care between resident physicians in inpatient settings, there has been minimal attention given to patient care transfers in academic ambulatory clinics. We sought to elicit the views of pediatric residents regarding year-end patient handoffs in a pediatric resident continuity clinic. Methods Residents assigned to a continuity clinic of a large pediatric residency program completed a questionnaire regarding year-end transfers of care. Results Thirty-one questionnaires were completed out of a total 45 eligible residents (69% response). Eighty seven percent of residents strongly or somewhat agreed that it would be useful to receive a written sign-out for patients with complex medical or social issues, but only 35% felt it would be useful for patients with no significant issues. Residents more frequently reported having access to adequate information regarding their new patients’ medical summary (53%) and care plan (47%) than patients’ functional abilities (30%), social history (17%), or use of community resources (17%). When rating the importance of receiving adequate sign-out in each those domains, residents gave most importance to the medical summary (87% of residents indicating very or somewhat important) and plan of care (84%). Residents gave less importance to receiving sign-out regarding their patients’ functional abilities (71%) social history (58%), and community resources (58%). Residents indicated that lack of access to adequate patient information resulted in additional work (80%), delays or omissions in needed care (56%), and disruptions in continuity of care (58%). Conclusions In a single-site study, residents perceive that they lack adequate information during year-end patient transfers

  14. Changes and Challenges of the 80s in Automating Federally Funded Ambulatory Care Clinics

    PubMed Central

    Kerlin, Barbara D.

    1985-01-01

    Recent years have witnessed challenges to our health care delivery system, in part as a result of changes to our economy. This paper describes the changing climate and discusses the increasing need of health care organizations for computer-based information to more efficiently manage their operations within a competitive and cost-conscious economy. Specific references are made to technology trends in clinics funded by the Federal Government for the health care of migrant workers.

  15. Providing palliative care in the ambulatory care setting.

    PubMed

    Griffith, Jane; Lyman, Jason A; Blackhall, Leslie J

    2010-04-01

    Palliative care that provides specialized attention to pain and symptom management is important for patients with cancer. Palliative care aims to reduce pain and other symptoms through an interdisciplinary approach involving physicians, nurses, social workers, and other members of the healthcare team. Families are included in care planning. Patients and families benefit from the availability of palliative care services early in the disease process, particularly when symptoms impact quality of life. One way to implement early palliative interventions is the establishment of an ambulatory care clinic dedicated to palliative care. This article describes the experience of an outpatient palliative care clinic at a large teaching hospital by using case studies to highlight the benefits of ambulatory palliative care and concluding with recommendations for research.

  16. Oral and Topical Antibiotics for Clinically Infected Eczema in Children: A Pragmatic Randomized Controlled Trial in Ambulatory Care

    PubMed Central

    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

    2017-01-01

    PURPOSE 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. METHODS 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). RESULTS 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. CONCLUSIONS 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. PMID:28289111

  17. Finding falls in ambulatory care clinical documents using statistical text mining

    PubMed Central

    McCart, James A; Berndt, Donald J; Jarman, Jay; Finch, Dezon K; Luther, Stephen L

    2013-01-01

    Objective To determine how well statistical text mining (STM) models can identify falls within clinical text associated with an ambulatory encounter. Materials and Methods 2241 patients were selected with a fall-related ICD-9-CM E-code or matched injury diagnosis code while being treated as an outpatient at one of four sites within the Veterans Health Administration. All clinical documents within a 48-h window of the recorded E-code or injury diagnosis code for each patient were obtained (n=26 010; 611 distinct document titles) and annotated for falls. Logistic regression, support vector machine, and cost-sensitive support vector machine (SVM-cost) models were trained on a stratified sample of 70% of documents from one location (dataset Atrain) and then applied to the remaining unseen documents (datasets Atest–D). Results All three STM models obtained area under the receiver operating characteristic curve (AUC) scores above 0.950 on the four test datasets (Atest–D). The SVM-cost model obtained the highest AUC scores, ranging from 0.953 to 0.978. The SVM-cost model also achieved F-measure values ranging from 0.745 to 0.853, sensitivity from 0.890 to 0.931, and specificity from 0.877 to 0.944. Discussion The STM models performed well across a large heterogeneous collection of document titles. In addition, the models also generalized across other sites, including a traditionally bilingual site that had distinctly different grammatical patterns. Conclusions The results of this study suggest STM-based models have the potential to improve surveillance of falls. Furthermore, the encouraging evidence shown here that STM is a robust technique for mining clinical documents bodes well for other surveillance-related topics. PMID:23242765

  18. Patient Satisfaction with Pharmacist-Led Collaborative Follow-Up Care in an Ambulatory Rheumatology Clinic.

    PubMed

    Hall, Jill J; Katz, Steven J; Cor, M Ken

    2017-09-01

    Patient satisfaction is known to increase with pharmacist intervention in general outpatient clinics and with nurse-led care in rheumatology clinics. The aim of the present study was to describe and compare patient satisfaction with two different types of care: a pharmacist physician collaborative model and a traditional physician model in a rheumatology clinic setting. A cross-sectional survey of inflammatory arthritis patients seen during a follow-up visit in Edmonton, Alberta, Canada, was conducted over a ten-week period. Patient satisfaction was measured using a modified version of the validated Leeds Satisfaction Questionnaire, which uses a five-point Likert scale to measure six dimensions of satisfaction, and compared between the collaborative care and traditional physician models. A total of 62 patients completed the questionnaire (21 collaborative care and 41 traditional physician model). The average age of respondents was 52 years and the majority were female. The mean score for satisfaction across the six dimensions was 4.56 in the collaborative care group and 4.30 in the traditional physician group (p = 0.02). Patient satisfaction in the collaborative care group was consistently higher across all dimensions. No difference was noted between participants seen for the first time compared with those seen two or more times by the pharmacist. A collaborative care model can exceed the already high expectations for care of patients with inflammatory arthritis. Our findings support the role of pharmacists using a collaborative care approach to care for patients in rheumatology clinics. Copyright © 2016 John Wiley & Sons, Ltd.

  19. Implementing university hospital ambulatory care evaluation.

    PubMed

    Goldberg, G A

    1975-05-01

    The clinics of a single university hospital center were observed to determine a practical rationale for and impediments to implementing a medical care evaluation program. A quality assurance mechanism is especially important in the ambulatory care setting because of problems with patient compliance, lack of policy continuity, lack of intercommunication among care providers, no counterpart for most inpatient quality-oriented activities, structural defects in many clinics, and general emphasis on the inpatient medicine. Impediments to implementing quality assurance programs include the condition of clinic records and individual charts, lack of established criteria for care, problems of care provider intercommunication during the evaluation process, manpower availability, choice of evaluation method, and method of implementing resulting plans for corrective action.

  20. Improving Clinical Workflow in Ambulatory Care: Implemented Recommendations in an Innovation Prototype for the Veteran’s Health Administration

    PubMed Central

    Patterson, Emily S.; Lowry, Svetlana Z.; Ramaiah, Mala; Gibbons, Michael C.; Brick, David; Calco, Robert; Matton, Greg; Miller, Anne; Makar, Ellen; Ferrer, Jorge A.

    2015-01-01

    NIST recommendations to improve workflow in ambulatory care using an EHR provide a first step in moving from a billing-centered perspective on how to maintain accurate, comprehensive, and up-to-date information about a group of patients to a clinician-centered perspective. These recommendations point the way towards a “patient visit management system,” which incorporates broader notions of supporting workload management, supporting flexible flow of patients and tasks, enabling accountable distributed work across members of the clinical team, and supporting dynamic tracking of steps in tasks that have longer time distributions. PMID:26290887

  1. Expressing clinical reasoning and uncertainties during a Thai internal medicine ambulatory care rotation: does the SNAPPS technique generalize?

    PubMed

    Sawanyawisuth, Kittisak; Schwartz, Alan; Wolpaw, Terry; Bordage, Georges

    2015-04-01

    SNAPPS is a learner-centered approach to case presentations that was shown, in American studies, to facilitate the expression of clinical reasoning and uncertainties in the outpatient setting. To evaluate the SNAPPS technique in an Asian setting. We conducted a quasi-experimental trial comparing the SNAPPS technique to the usual-and-customary method of case presentations for fifth-year medical students in an ambulatory internal medicine clerkship rotation at Khon Kaen University, Thailand. We created four experimental groups to test main and maturation effects. We measured 12 outcomes at the end of the rotations: total, summary, and discussion presentation times, number of basic clinical findings, summary thoroughness, number of diagnoses in the differential, number of justified diagnoses, number of basic attributes supporting the differential, number of student-initiated questions or discussions about uncertainties, diagnosis, management, and reading selections. SNAPPS users (90 case presentations), compared with the usual group (93 presentations), had more diagnoses in their differentials (1.81 vs. 1.42), more basic attributes to support the differential (2.39 vs. 1.22), more expression of uncertainties (6.67% vs. 1.08%), and more student-initiated reading selections (6.67% vs. 0%). Presentation times did not differ between groups (12 vs. 11.2 min). There were no maturation effects detected. The use of the SNAPPS technique among Thai medical students during their internal medicine ambulatory care clerkship rotation did facilitate the expression of their clinical reasoning and uncertainties. More intense student-preceptor training is needed to better foster the expression of uncertainties.

  2. Helping You Choose Quality Ambulatory Care

    MedlinePlus

    Helping you choose: Quality ambulatory care When you need ambulatory care, you should find out some information to help you choose the best ... the center follows rules for patient safety and quality. Go to Quality Check ® at www. qualitycheck. org ...

  3. Patient and clinician communication of self-reported insomnia during ambulatory cancer care clinic visits.

    PubMed

    Siefert, Mary Lou; Hong, Fangxin; Valcarce, Bianca; Berry, Donna L

    2014-01-01

    Insomnia, the most commonly reported sleep-wake disturbance in people with cancer, has an adverse effect on quality of life including emotional well-being, distress associated with other symptoms, daily functioning, relationships, and ability to work. The aim of this study was to describe the content of discussions between clinicians and 120 patients with self-reported insomnia and to examine the associations of sociodemographic, clinical, and environmental factors with insomnia. A secondary analysis was conducted with self-reported symptom data and sociodemographic, clinical, and environmental factors. Recordings of clinician and patient discussions during clinic visits were examined by conducting a content analysis. Severe insomnia was more likely to be reported by women, minority, and lower-income individuals. Seven major topics were identified in the discussions. The clinicians did not always discuss insomnia; discussion rates differed by diagnosis and clinical service. Reporting of insomnia by the patient and clinician communication about insomnia may have differed by demographic and clinical characteristics. Clinicians attended to insomnia about half the time with management strategies likely to be effective. Explanations may be that insomnia had a low clinician priority for the clinic visit or lack of clear evidence to support insomnia interventions. A better understanding is needed about why insomnia is not addressed even when reported by patients; it is well known that structured assessments and early interventions can improve quality of life. Research is warranted to better understand potential disparities in cancer care.

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

    PubMed

    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.

  5. Measuring interdependence in ambulatory care.

    PubMed

    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.

  6. Impact of Patient-Centered Care Innovations on Access to Providers, Ambulatory Care Utilization, and Patient Clinical Indicators in the Veterans Health Administration.

    PubMed

    Burkhart, Lisa; Sohn, Min-Woong; Jordan, Neil; Tarlov, Elizabeth; Gampetro, Pamela; LaVela, Sherri L

    2016-01-01

    The Veterans Health Administration piloted patient-centered care (PCC) innovations beginning in 2010 to improve patient and provider experience and environment in ambulatory care. We use secondary data to look at longitudinal trends, evaluate system redesign, and identify areas for further quality improvement. This was a retrospective, observational study using existing secondary data from multiple US Department of Veteran Affairs sources to evaluate changes in veteran and facility outcomes associated with PCC innovations at 2 innovation and matched comparison sites between FY 2008-2010 (pre-PCC innovations) and FY 2011-2012 (post-PCC innovations). Outcomes included access to primary care providers (PCPs); primary, specialty, and emergency care use; and clinical indicators for chronic disease. Longitudinal trends revealed a different story at each site. One site demonstrated better PCP access, decrease in emergency and primary care use, increase in specialty care use, and improvement in diabetic glucose control. The other site demonstrated a decrease in PCP access and primary care use, no change in specialty care use, and an increase in diastolic blood pressure in relation to the comparison site. Secondary data analysis can reveal longitudinal trends associated with system changes, thereby informing program evaluation and identifying opportunities for quality improvement.

  7. Ambulatory visit groups: a framework for measuring productivity in ambulatory care.

    PubMed Central

    Fetter, R B; Averill, R F; Lichtenstein, J L; Freeman, J L

    1984-01-01

    This article describes Ambulatory Visit Groups (AVGs) and the process by which they were defined. An approach to the analysis of physician productivity in the ambulatory setting is then demonstrated, with data derived from the National Ambulatory Medical Care Survey [1]. Finally, recommendations for future work are presented to make this approach more effective in designing and managing ambulatory care delivery organizations. PMID:6490373

  8. Metadata - National Hospital Ambulatory Medical Care Survey (NHAMCS)

    EPA Pesticide Factsheets

    The National Hospital Ambulatory Medical Care Survey (NHAMCS) is designed to collect information on the services provided in hospital emergency and outpatient departments and in ambulatory surgery centers.

  9. Accreditation Association for Ambulatory Health Care

    MedlinePlus

    ... Overview Surveyors About Us History Board of Directors & Association Members Staff Annual Report Board/Committee Portal Careers ... Toolkits An introduction to AAAHC Copyright © 2017 Accreditation Association for Ambulatory Health Care Contact Us P: 847. ...

  10. Virtual ambulatory care. Computer simulation applications.

    PubMed

    Zilm, Frank; Culp, Kristyna; Dorney, Beverley

    2003-01-01

    Computer simulation modeling has evolved during the past twenty years into an effective tool for analyzing and planning ambulatory care facilities. This article explains the use of this tool in three case-study, ambulatory care settings--a GI lab, holding beds for a cardiac catheterization laboratory, and in emergency services. These examples also illustrate the use of three software packages currently available: MedModel, Simul8, and WITNESS.

  11. Designing appointment scheduling systems for ambulatory care services.

    PubMed

    Cayirli, Tugba; Veral, Emre; Rosen, Harry

    2006-02-01

    The current climate in the health care industry demands efficiency and patient satisfaction in medical care delivery. These two demands intersect in scheduling of ambulatory care visits. This paper uses patient and doctor-related measures to assess ambulatory care performance and investigates the interactions among appointment system elements and patient panel characteristics. Analysis methodology involves simulation modeling of clinic sessions where empirical data forms the basis of model design and assumptions. Results indicate that patient sequencing has a greater effect on ambulatory care performance than the choice of an appointment rule, and that panel characteristics such as walk-ins, no-shows, punctuality and overall session volume, influence the effectiveness of appointment systems.

  12. 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.

    PubMed

    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.

  13. 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

    PubMed Central

    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. PMID:25032688

  14. Satisfaction With Medication Therapy Management Services at a University Ambulatory Care Clinic.

    PubMed

    Kim, Shiyun; Martin, Michelle T; Pierce, Andrea L; Zueger, Patrick

    2016-06-01

    A survey was issued to patients enrolled in the Medication Therapy Management Clinic (MTMC) at University of Illinois Hospital and Health Sciences (June 2011-January 2012) in order to assess satisfaction with pharmacy services provided by pharmacists. A 23-item survey was offered to 65 patients in the MTMC program before or after clinic visits. Since there is a paucity of data indicating the level of satisfaction with MTM services provided by pharmacists, this survey may contribute to the process of building a greater collaboration between the pharmacist and patient. Sixty-two of 65 patients completed the survey; satisfaction with MTMC pharmacists was demonstrated to be significantly positively correlated with overall satisfaction with the MTMC. Patient satisfaction is not significantly different according to age, gender, ethnicity, or number of disease states. Satisfaction with the pillbox service is not significantly different between younger and older patients. It was also noted that patients taking a greater number of medications had higher levels of satisfaction. Most patients indicated that they were satisfied with the MTMC pharmacists and services; further study linking patient satisfaction with MTM services to improved patient outcomes may allow our MTMC to serve as a model for other pharmacist-managed MTMCs serving similar patient populations.

  15. Educational Strategies in Ambulatory Care

    ERIC Educational Resources Information Center

    Barker, Lee R.

    1978-01-01

    In 1974 an ambulatory practice was developed for the house staff in the Department of Medicine at Baltimore City Hospital and integrated into the traditional residency program, which is based upon block rotations in inpatient services, emergency service, and subspeciality electives. The goals and strategies of this program are described. (LB H)

  16. Ambulatory care: a decade of evolution.

    PubMed

    Welch, Leslie

    2009-01-01

    Leslie Welch, a director at HLM Architects, explains how new generation, well-equipped ambulatory and emergency care centres, a relatively new development in the UK, are offering local day care patients a holistic healthcare service in a high quality setting, while reducing pressure on general hospitals and cutting waiting times.

  17. Diagnostic Errors in Ambulatory Care: Dimensions and Preventive Strategies

    ERIC Educational Resources Information Center

    Singh, Hardeep; Weingart, Saul N.

    2009-01-01

    Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors. To explore the extent and nature of diagnostic errors in ambulatory care, we identified five dimensions of ambulatory care from which errors may…

  18. Understanding the Costs of Ambulatory Care Training.

    ERIC Educational Resources Information Center

    Boex, James R.; Blacklow, Robert; Boll, Arthur; Fishman, Linda; Gamliel, Sandy; Garg, Mohan; Gilchrist, Valerie; Hogan, Andrew; Meservey, Patricia; Pearson, Steven; Politzer, Robert; Veloski, J. Jon

    1998-01-01

    Describes a model for ambulatory health care training that makes it easier to generalize about and quantify educational costs. The model is built around two major variable sets affecting costs: (1) three cost types (direct, indirect, infrastructure), and (2) factors related to training site and educational activities. It is constructed to show how…

  19. Memo to: Ambulatory Health Care Planners.

    ERIC Educational Resources Information Center

    Educational Facilities Labs., Inc., New York, NY.

    Planning for changing types of health professions and a changing clientele necessitates designing flexible facilities. Findings from a recently completed analysis of ambulatory care facilities are directed to planners in the form of 16 memos. Approaches to planning and design considerations are made that attempt to humanize these facilities.…

  20. Complexity of ambulatory care across disciplines.

    PubMed

    Katerndahl, David; Wood, Robert; Jaén, Carlos Roberto

    2015-06-01

    Complexity of care has implications for quality of care, health costs, medical errors, and patient and physician satisfaction. The objective was to compare complexity of ambulatory care across 14 medical specialties. This secondary analysis uses the 2010 National Ambulatory Medical Care Survey, which used a multistage probability design of primary sampling units throughout U.S. ambulatory practices across 14 specialties. Sampling weights enable results from 29,179 ambulatory visits to represent 878,653,561 visits. Data included symptoms, diagnoses, diagnostic procedures, and treatments provided. Measures of input, output and total encounter complexity and hourly complexity densities were computed. Internal Medicine leads in total input and total encounter complexity with Family Medicine second in total encounter complexity. When duration-of-visit is considered, Family Medicine is the most complex discipline while Internal Medicine is the second most complex. Pediatrics lacks the complexity of Family Medicine and General Internal Medicine, and OB/GYN bears little similarity to Family Medicine or General Internal Medicine. Family Medicine and Internal Medicine encounters are the most complex overall, especially when duration-of-visit is considered. Revaluing payments based on complexity could bring better balance to cognitive and procedural services, and better meet the needs of people receiving insurance under the ACA. Copyright © 2015 Elsevier Inc. All rights reserved.

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

    PubMed

    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.

  2. Comparing patients seen in pediatric resident continuity clinics and national ambulatory medical care survey practices: a study from the continuity research network.

    PubMed

    Serwint, Janet R; Thoma, Kathleen A; Dabrow, Sharon M; Hunt, Lynn E; Barratt, Michelle S; Shope, Timothy R; Darden, Paul M

    2006-09-01

    The goal was to compare visit data from Continuity Research Network practices with data for a nationally representative sample of pediatric visits in practice settings from the National Ambulatory Medical Care Survey. A cross-sectional study comparing data for Continuity Research Network practice visits during a 1-week period in 2002 with data from the 2000 National Ambulatory Medical Care Survey was performed. Continuity Research Network and National Ambulatory Medical Care Survey data were derived from 30 patient visits per practice site for patients < 22 years of age, with the primary care providers being residents and practicing pediatricians, respectively. Eighteen Continuity Research Network practices reported on 540 visits, compared with 32 National Ambulatory Medical Care Survey physicians reporting on 792 visits. Continuity Research Network patients were more likely to be black non-Hispanic or Hispanic/Latino and to have public insurance. The top 5 reasons for visits were the same for Continuity Research Network and National Ambulatory Medical Care Survey visits, although the orders varied slightly. These 5 reasons accounted for 58% of Continuity Research Network visits and 49% of National Ambulatory Medical Care Survey visits. Continuity Research Network visits were more likely to result in patient instructions to return at a specific time (78% vs 52%). Residents in Continuity Research Network practices provide care to more underserved patients but evaluate problems that are similar to those observed in office practices; the Continuity Research Network practices thus provide important training experiences for residents who will serve both minority and nonminority children.

  3. Delineating the Ambulatory Care Nursing Activities in the Navy Medical Department. Phase 1. Workload Management System for Nursing Ambulatory Care Project

    DTIC Science & Technology

    1987-04-01

    between the levels of intensity of nursing care found in the emergency department compared to the leve’s found in outpatient clinics. CONCLUSION: The...requirements for nursing care personnel. The planned methodology of Phases II and III are discussed further in Appendix B. An extensive review of the...be generalizable across a variety of ambulatory settings (Verran, 1986, p. 250). The ACCCI quantifies the complexity of nursing care in the ambulatory

  4. Patient Perceptions of Mistakes in Ambulatory Care

    PubMed Central

    Kistler, Christine E.; Walter, Louise C.; Mitchell, C. Madeline; Sloane, Philip D.

    2011-01-01

    CONTEXT Little information exists about current patient perceptions of medical mistakes in ambulatory care within a diverse population. OBJECTIVES To learn about adults’ perceptions of mistakes in ambulatory care, what factors were associated with perceived mistakes, and whether or not the respondents changed physicians because of these perceived mistakes DESIGN Cross-sectional survey conducted in 2008 SETTING Seven primary care medical practices in North Carolina PARTICIPANTS One thousand six hundred ninety-seven English or Spanish speaking adults, aged 18 and older, who presented to a medical provider during the data collection period. MAIN OUTCOME MEASURES 1) Has a doctor in a doctor’s office ever made a mistake in your care? 2) In the past 10 years, has a doctor in a doctor’s office made a wrong diagnosis or misdiagnosed you? (If yes, how much harm did this cause you?) 3) In the last 10 years, has a doctor in a doctor’s office given you the wrong medical treatment or delayed treatment? (If yes, how much harm did this cause you?) 4) Have you ever changed doctors because of either a wrong diagnosis or a wrong treatment of a medical condition? RESULTS Two hundred sixty-five participants (15.6%) responded that a doctor had ever made a mistake, 13.4% reported a wrong diagnosis, 12.4% reported a wrong treatment, and 14.1% reported having changed doctors because of a mistake. Participants perceived mistakes and harm in both diagnostic care and medical treatment. Patients with chronic low back pain, higher levels of education, and poor physical health were at increased odds of perceiving harm, whereas African-Americans were less likely to perceive mistakes. CONCLUSIONS Patients perceived mistakes in their diagnostic and treatment care in the ambulatory setting. These perceptions had a concrete impact on the patient-physician relationship, often leading patients to seek another health care provider. PMID:20837835

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

    PubMed

    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 < .001). The risk ratio of achieving and maintaining the goal blood pressure in patients of active care management group was 5.44, CI (3.2-9.9; P = .005). Implementation of active ambulatory care management supported by short message services and mobile phone improves the quality of ambulatory care of hypertensive patients.

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

    PubMed

    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

  7. Are physicians with better clinical skills on licensing examinations less likely to prescribe antibiotics for viral respiratory infections in ambulatory care settings?

    PubMed

    Cadieux, Genevieve; Abrahamowicz, Michal; Dauphinee, Dale; Tamblyn, Robyn

    2011-02-01

    Viral respiratory infections (VRIs) are a common reason for ambulatory visits, and 35% are treated with an antibiotic. Antibiotic use for VRIs is not recommended, and it promotes antibiotic resistance. Effective patient-physician communication is critical to address this problem. Recognizing the importance of physician communication skills, licensure examinations were reformed in the United States and Canada to evaluate these skills. To assess whether physician clinical and communication skills, as measured by the Canadian clinical skills examination (CSE), predict antibiotic prescribing for VRI in ambulatory care. A total of 442 Quebec general practitioners and pediatricians who wrote the CSE in 1993-1996 were followed from 1993 to 2007, and their 159,456 VRI visits were identified from physician claims. The outcome was an antibiotic prescription from a study physician dispensed within 7 days of the VRI visit. Multivariate logistic regression analyses were used to estimate the association between antibiotic prescribing for VRI and CSE score, adjusting for physician, patient, and encounter characteristics. Better clinical and communication skills were associated with a reduction in the risk of antibiotic prescribing, but only for female physicians. Every 1-standard deviation increase in CSE score was associated with a 19% reduction in the risk of antibiotic prescribing (risk ratio, 0.81; 95% confidence interval, 0.68-0.97). Better clinical skills were associated with an even greater reduction in risk among female physicians with higher workloads (risk ratio, 0.48; 95% confidence interval, 0.29-0.79). Physician clinical and communication skills are important determinants of antibiotic prescribing for VRI and should be targeted by future interventions.

  8. The Ambulatory Care Workload Management System for Nursing Reference Manual

    DTIC Science & Technology

    1991-05-31

    AD-A237 257l ~llli~llll/llUt!/~llll =. STA TZS" ! = t THE AMBULATORY CARE WORKLOAD MANAGEMENT SYSTEM FOR NURSING REFERENCE MANUAL MAY 1991 NAVAL...TASK WORK UN ELEMENTNO. NO. NO. ACCESSION 11 TITLE (Include Securrty Gasfication) The Ambulatory Care Workload Management System for Nursing...obsolete. JC~CURMT CLASSIPICATIO" OF THIS PA09 The Ambulatory Care Workload Management System for Nursing (AC/WMSN) is a patient classification and

  9. Medication reconciliation interventions in ambulatory care: A scoping review.

    PubMed

    McCarthy, Lisa; Su, Xinru Wendy; Crown, Natalie; Turple, Jennifer; Brown, Thomas E R; Walsh, Kate; John, Jessica; Rochon, Paula

    2016-11-15

    The published literature on medication reconciliation (MR) interventions, outcomes, and facilitators in ambulatory care settings is reviewed. A scoping review was conducted to characterize ambulatory care-based MR research in terms of study design, elements of interventions, and outcomes examined. English-language articles on comparative studies of MR programs targeting adults in ambulatory care settings were identified using data sources including MEDLINE, PreMEDLINE, EMBASE, and International Pharmaceutical Abstracts. For each study, steps undertaken in the MR process were extracted. The Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy was used to classify types of interventions; taxonomies for reported outcomes and factors facilitating implementation of MR initiatives were developed by the authors. From among 2062 publications screened, 15 were included in the review. In 13 studies, multiple data sources were used to compile a "best possible medication history" (BPMH); however, the BPMH was shared with external healthcare providers in only 4 studies and with patients in only 5 studies. Most reported MR interventions were classified into two EPOC domains: professional (predominantly educational outreach visits and patient reminders) and organizational (predominantly provider-oriented interventions). Process outcomes were reported in 12 studies, with correct performance of MR being the most commonly evaluated process outcome, and 9 studies identified factors that facilitated MR implementation. Few studies have examined clinical outcomes of MR in ambulatory care settings, with the majority of pertinent reports focusing instead on process outcomes. Facilitators of successful MR interventions have been identified at the patient, staff, and clinic setting levels. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

  10. A Medical Classification System for Ambulatory-care Manpower Planning

    PubMed Central

    Schneider, Donald P.; Kilpatrick, Kerry E.

    1974-01-01

    The Trilevel Classification System described adapts the useful features of existing classification systems for convenient use in health manpower analysis. A computer program links the Kaiser Clinical-Behavioral Classification system, oriented to the demographic and socioeconomic characteristics of patient populations using ambulatory-care services, with the Geomet Specifications of Care, which in turn utilizes ICDA-coded records and Current Procedural Terminology—coded elements of care. An extensive case study is discussed in which the system is used in an HMO to predict the differential effects of various delegation policies for physician assistants. PMID:4154928

  11. Resource requirements for evaluating ambulatory health care.

    PubMed Central

    Thompson, M S; Palmer, R H; Rothrock, J K; Strain, R; Brachman, L H; Wright, E A

    1984-01-01

    We implemented the most frequently used form of quality assurance activity: abstracting information on the quality of patient care from medical records and communicating findings to providers in 16 ambulatory care groups. Site providers accepted the evaluation criteria, agreed that deficiencies in care were detected, and, for some medical tasks, effected improvements in care. Direct costs in 1980 dollars for the quality assurance cycle including data system development were $46 per evaluated case. Per-case costs varied considerably among tasks, decreased with larger numbers of cases and as experience grew, and were reduced through computerization. Measured costs were high due to: a demanding research design; our extended accounting of direct, indirect, and induced costs; and the substantial resource requirements of rigorously performed evaluations. PMID:6496817

  12. Development of an Integrated Ambulatory Care Database and Analysis System

    PubMed Central

    Panzer, Robert J.; Ostrowski, Carol P.; Gerek, Mary-Louise; Reiners, Carolyn A.; Rumble, Christine M.; Kraus, Ronald M.; Engerman, Judith R.; Katsanis, Gary L.

    1988-01-01

    This report describes the development of an integrated, comprehensive system for analysis of ambulatory care practices. The system includes a network of hospital-based and community-based physician practices in the Rochester, New York area. After coding and data entry, routine clinical information from network practices, including demographics, diagnoses, and procedures, is submitted in computer readable form to be integrated with inpatient, emergency department, and outpatient information extracted from a hospital information system. This integrated information is transformed into patient-related and encounter-related SAS files ready for reporting and analysis. This system provides a research laboratory for examination of ambulatory care practices that combines features of both claims-based databases and cooperative practice networks.

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

    PubMed

    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.

  14. Antibiotic stewardship: a focus on ambulatory care.

    PubMed

    Gangat, M Azhar; Hsu, Jennifer L

    2015-01-01

    Antibiotic resistance is one of the major health threats facing modern medicine. While there are many tactics to address this issue, antibiotic stewardship has been shown effective in reducing antimicrobial resistance, adverse drug effects, mortality and health care cost. Most antibiotic stewardship programs have evolved within acute care settings where the bulk of resistant infections are identified. Unfortunately, hospitals are just the tip of the iceberg in terms of overall antibiotic use. The vast majority of the antibiotic prescriptions are dispensed in ambulatory care settings, making this a critical target for stewardship programs. This article discusses the global need for antibiotic stewardship, highlights the importance of outpatient stewardship, and discusses strategies and challenges for implementation of stewardship in community settings.

  15. Use of extramural ambulatory care curricula in postgraduate medical training.

    PubMed

    Talwalkar, Jaideep S; Satcher, D'Juanna; Turner, Teri L; Sisson, Stephen D; Fenick, Ada M

    2015-04-01

    Extramural curricula developed for the purpose of sharing with other institutions have been designed to improve education on important topics in ambulatory care. We sought to assess the usage rates of these curricula among paediatric, internal medicine, and combined medicine-paediatrics residency programmes in the United States. Surveys on aspects of trainee continuity clinic were sent to paediatric and medicine-paediatrics programme directors in 2012. Surveys contained an item asking respondents about their use of extramural ambulatory care curricula. Since no similar recent data were available for internal medicine, and to verify the accuracy of the paediatric survey data, we queried the editors of four widely used curricula for subscription information. Descriptive and inferential statistics were calculated. Responses from paediatric programmes indicated that 48 of 111 (43 %) were using an extramural curriculum, compared with 39 of 60 (65 %) medicine-paediatrics programmes (p = 0.007). Editor query revealed a collective subscription rate of internal medicine programmes (300 of 402, 75 %), which was greater than the subscription rate of paediatric programmes (90 of 201, 45 %) (p < 0.001). Training programmes in paediatrics, internal medicine, and combined medicine-paediatrics utilize extramural curricula to guide education in ambulatory care, but internal medicine and medicine-paediatrics programmes employ these curricula at greater rates than paediatric programmes.

  16. Description of practice as an ambulatory care nurse: psychometric properties of a practice-analysis survey.

    PubMed

    Baghi, Heibatollah; Panniers, Teresa L; Smolenski, Mary C

    2007-01-01

    Changes within nursing demand that a specialty conduct periodic, appropriate practice analyses to continually validate itself against preset standards. This study explicates practice analysis methods using ambulatory care nursing as an exemplar. Data derived from a focus group technique were used to develop a survey that was completed by 499 ambulatory care nurses. The validity of the instrument was assessed using principal components analysis; reliability was estimated using Cronbach's alpha coefficient. The focus group with ambulatory care experts produced 34 knowledge and activity statements delineating ambulatory care nursing practice. The survey data produced five factors accounting for 71% of variance in the data. The factors were identified as initial patient assessment, professional nursing issues and standards, client care management skills, technical/clinical skills, and system administrative operations. It was concluded that practice analyses delineate a specialty and provide input for certification examinations aimed at measuring excellence in a field of nursing.

  17. Prescribing pharmacists in the ambulatory care setting: Experience at the University of North Carolina Medical Center.

    PubMed

    Hawes, Emily M; Misita, Caron; Burkhart, Jena Ivey; McKnight, Lauren; Deyo, Zachariah M; Lee, Ruth-Ann; Howard, Caroline; Eckel, Stephen F

    2016-09-15

    The prescribing authorities, clinical activities, and productivity documentation strategies of ambulatory care clinic-based pharmacists practicing within a large academic health system are described. North Carolina law encourages progressive pharmacy practice through acquisition of the clinical pharmacist practitioner (CPP) designation. Qualified CPPs are authorized to provide collaborative drug therapy management services, including medication prescribing and ordering of laboratory tests, according to defined protocols and under physician supervision. The University of North Carolina Medical Center has approximately 30 CPPs deployed across a wide range of ambulatory care clinical practice sites. This article describes (1) the pharmacy department's implementation of an ambulatory care practice model, (2) the credentialing and privileging process leading to granting of prescribing privileges, (3) metrics used to demonstrate the impact of CPP activities, (4) recommended general criteria for ambulatory care practice site identification, and (5) strategies for overcoming barriers to successful implementation of ambulatory care-focused clinical pharmacist services. Aggregated intervention-tracking data compiled by seven of the medical center's CPP ambulatory care practice sites indicate extensive CPP involvement in direct patient care encounters and patient or provider consultations, with large numbers of medication-related interventions to support institutional cost-avoidance and revenue goals. CPPs deployed at the medical center's ambulatory care clinics have had a positive impact on clinical and cost outcomes, improving patient care through interventions, contributing to readmission reduction efforts, generating indirect revenue through cost avoidance, and generating new revenue through billing for patient visits. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

  18. How well do clinical prediction rules perform in identifying serious infections in acutely ill children across an international network of ambulatory care datasets?

    PubMed

    Verbakel, Jan Y; Van den Bruel, Ann; Thompson, Matthew; Stevens, Richard; Aertgeerts, Bert; Oostenbrink, Rianne; Moll, Henriette A; Berger, Marjolein Y; Lakhanpaul, Monica; Mant, David; Buntinx, Frank

    2013-01-15

    Diagnosing serious infections in children is challenging, because of the low incidence of such infections and their non-specific presentation early in the course of illness. Prediction rules are promoted as a means to improve recognition of serious infections. A recent systematic review identified seven clinical prediction rules, of which only one had been prospectively validated, calling into question their appropriateness for clinical practice. We aimed to examine the diagnostic accuracy of these rules in multiple ambulatory care populations in Europe. Four clinical prediction rules and two national guidelines, based on signs and symptoms, were validated retrospectively in seven individual patient datasets from primary care and emergency departments, comprising 11,023 children from the UK, the Netherlands, and Belgium. The accuracy of each rule was tested, with pre-test and post-test probabilities displayed using dumbbell plots, with serious infection settings stratified as low prevalence (LP; <5%), intermediate prevalence (IP; 5 to 20%), and high prevalence (HP; >20%) . In LP and IP settings, sensitivity should be >90% for effective ruling out infection. In LP settings, a five-stage decision tree and a pneumonia rule had sensitivities of >90% (at a negative likelihood ratio (NLR) of < 0.2) for ruling out serious infections, whereas the sensitivities of a meningitis rule and the Yale Observation Scale (YOS) varied widely, between 33 and 100%. In IP settings, the five-stage decision tree, the pneumonia rule, and YOS had sensitivities between 22 and 88%, with NLR ranging from 0.3 to 0.8. In an HP setting, the five-stage decision tree provided a sensitivity of 23%. In LP or IP settings, the sensitivities of the National Institute for Clinical Excellence guideline for feverish illness and the Dutch College of General Practitioners alarm symptoms ranged from 81 to 100%. None of the clinical prediction rules examined in this study provided perfect diagnostic accuracy

  19. How well do clinical prediction rules perform in identifying serious infections in acutely ill children across an international network of ambulatory care datasets?

    PubMed Central

    2013-01-01

    Background Diagnosing serious infections in children is challenging, because of the low incidence of such infections and their non-specific presentation early in the course of illness. Prediction rules are promoted as a means to improve recognition of serious infections. A recent systematic review identified seven clinical prediction rules, of which only one had been prospectively validated, calling into question their appropriateness for clinical practice. We aimed to examine the diagnostic accuracy of these rules in multiple ambulatory care populations in Europe. Methods Four clinical prediction rules and two national guidelines, based on signs and symptoms, were validated retrospectively in seven individual patient datasets from primary care and emergency departments, comprising 11,023 children from the UK, the Netherlands, and Belgium. The accuracy of each rule was tested, with pre-test and post-test probabilities displayed using dumbbell plots, with serious infection settings stratified as low prevalence (LP; <5%), intermediate prevalence (IP; 5 to 20%), and high prevalence (HP; >20%) . In LP and IP settings, sensitivity should be >90% for effective ruling out infection. Results In LP settings, a five-stage decision tree and a pneumonia rule had sensitivities of >90% (at a negative likelihood ratio (NLR) of < 0.2) for ruling out serious infections, whereas the sensitivities of a meningitis rule and the Yale Observation Scale (YOS) varied widely, between 33 and 100%. In IP settings, the five-stage decision tree, the pneumonia rule, and YOS had sensitivities between 22 and 88%, with NLR ranging from 0.3 to 0.8. In an HP setting, the five-stage decision tree provided a sensitivity of 23%. In LP or IP settings, the sensitivities of the National Institute for Clinical Excellence guideline for feverish illness and the Dutch College of General Practitioners alarm symptoms ranged from 81 to 100%. Conclusions None of the clinical prediction rules examined in this study

  20. Growing ambulatory care nurse leaders in a multigenerational workforce.

    PubMed

    Moye, Janet P; Swan, Beth Ann

    2009-01-01

    Ambulatory care faces challenges in sustaining a nursing workforce in the future as newly licensed nurses are heavily recruited to inpatient settings and retirements will impact ambulatory care sooner than other areas. Building a diverse team by recruiting nurses of different ages (generations) and skills may result in a more successful and robust organization. Knowledge about generational characteristics and preferences will aid nurse leaders and recruiters in attracting high-quality, talented nurses. Nurses of Generations X and Y can increase their likelihood of success in ambulatory care by better understanding intergenerational issues.

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

    PubMed

    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.

  2. Evaluation of a Professional Practice Model in the Ambulatory Care Setting

    DTIC Science & Technology

    2014-03-10

    patient satisfaction , nurse -sensitive indicators of quality care as measured by...Project Number: N10-C04 Aim one Evaluate levels of nursing and patient satisfaction in ambulatory care clinics following implementation of a...Clarke, S.P., Sloane, D., Lake, E.T., Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing

  3. Commentary on the required skills for ambulatory cardiac care in the young: is training necessary?

    PubMed

    Boris, Jeffrey R

    2015-12-01

    Extensive supplemental training exists for many subspecialty disciplines within fellowship training for paediatric cardiology in the United States of America. These disciplines, or domains, such as echocardiography, cardiac intensive care, interventional cardiology, and electrophysiology, allow for initial exposure and training during the basic 3 years of fellowship, plus mandate a 4th year of advanced training; however, ambulatory cardiology has no in-depth or additional training beyond the basic clinical exposure during fellowship training. Ambulatory cardiology is not included in the recommended scheduling of the various domains of cardiology training. This document reviews the reasons to consider augmenting the depth and breadth of training in ambulatory paediatric cardiology.

  4. Comparing the Quality of Ambulatory Surgical Care for Skin Cancer in a Veterans Affairs Clinic and a Fee-For-Service Practice Using Clinical and Patient-Reported Measures

    PubMed Central

    Linos, Eleni; Arron, Sarah T.; Hills, Nancy K.

    2017-01-01

    The Institute of Medicine has identified serious deficiencies in the measurement of cancer care quality, including the effects on quality of life and patient experience. Moreover, comparisons of quality in Veterans Affairs Medical Centers (VA) and other sites are timely now that many Veterans can choose where to seek care. To compare quality of ambulatory surgical care for keratinocyte carcinoma (KC) between a VA and fee-for-service (FFS) practice, we used unique clinical and patient-reported data from a comparative effectiveness study. Patients were enrolled in 1999–2000 and followed for a median of 7.2 years. The practices differed in a few process measures (e.g., median time between biopsy and treatment was 7.5 days longer at VA) but there were no substantial or consistent differences in clinical outcomes or a broad range of patient-reported outcomes. For example, 5-year tumor recurrence rates were equally low (3.6% [2.3–5.5] at VA and 3.4% [2.3–5.1] at FFS), and similar proportions of patients reported overall satisfaction at one year (78% at VA and 80% at FFS, P = 0.69). These results suggest that the quality of care for KC can be compared comprehensively in different health care systems, and suggest that quality of care for KC was similar at a VA and FFS setting. PMID:28141817

  5. Expanding Ambulatory Care Pharmacy Residency Education Through a Multisite University-Affiliated Model.

    PubMed

    Schweiss, Sarah K; Westberg, Sarah M; Moon, Jean Y; Sorensen, Todd D

    2017-01-01

    As the health-care system evolves and shifts to value-based payment systems, there is a recognized need to increase the number of ambulatory care trained pharmacists. The objective of this article is to describe the administrative structure of the University of Minnesota Postgraduate Year 1 (PGY1) Pharmacy Residency program and to encourage adoption of similar models nationally in order to expand ambulatory care residency training opportunities and meet the demand for pharmacist practitioners. Program Structure: The University of Minnesota PGY1 Pharmacy Residency program is a multisite program centered on the practice of pharmaceutical care and provision of comprehensive medication management (CMM) services in ambulatory care settings. The centralized administration of a multisite academic-affiliated training model creates efficiency in the administration process, while allowing sites to focus on clinical training. This model also offers many innovative and unique opportunities to residents. A multisite university-affiliated ambulatory care residency training model provides efficiency in program administration, while successfully accelerating the growth of quality ambulatory care residency training and supporting innovative delivery of shared core learning experiences. Consequently, practice sites grow in their service delivery capacity and quality of care.

  6. [The shift towards ambulatory care, from wishful thinking to practice].

    PubMed

    Pierru, Frédéric

    2016-01-01

    For several years, there has been a distinct political will for the development of home care. However, this shift to ambulatory care, a source of financial savings for the health system and comfort for the patient, requires sociological debate. Notable issues for discussion are the social inequalities caused by this evolution and the role of the family in the care.

  7. Cost sharing and hospitalizations for ambulatory care sensitive conditions.

    PubMed

    Arrieta, Alejandro; García-Prado, Ariadna

    2015-01-01

    During the last decade, Chile's private health sector has experienced a dramatic increase in hospitalization rates, growing at four times the rate of ambulatory visits. Such evolution has raised concern among policy-makers. We studied the effect of ambulatory and hospital co-insurance rates on hospitalizations for ambulatory care sensitive conditions (ACSC) among individuals with private insurance in Chile. We used a large administrative dataset of private insurance claims for the period 2007-8 and a final sample of 2,792,662 individuals to estimate a structural model of two equations. The first equation was for ambulatory visits and the second for future hospitalizations for ACSC. We estimated the system by Two Stage Least Squares (2SLS) corrected by heteroskedasticity via Generalized Method of Moments (GMM) estimation. Results show that increased ambulatory visits reduced the probability of future hospitalizations, and increased ambulatory co-insurance decreased ambulatory visits for the adult population (19-65 years-old). Both findings indicate the need to reduce ambulatory co-insurance as a way to reduce hospitalizations for ACSC. Results also showed that increasing hospital co-insurance does have a statistically significant reduction on hospitalizations for the adult group, while it does not seem to have a significant effect on hospitalizations for the children (1-18 years-old) group. This paper's contribution is twofold: first, it shows how the level of co-insurance can be a determinant in avoiding unnecessary hospitalizations for certain conditions; second, it highlights the relevance for policy-making of using data on ACSC to improve the efficiency of health systems by promoting ambulatory care as well as population health. Copyright © 2014 Elsevier Ltd. All rights reserved.

  8. The influence factors of medical professionalism: A stratified-random sampling study based on the physicians and patients in ambulatory care clinics of Chengdu, China.

    PubMed

    Lin, Yifei; Yin, Senlin; Lai, Sike; Tang, Ji; Huang, Jin; Du, Liang

    2016-10-01

    As the relationship between physicians and patients deteriorated in China recently, medical conflicts occurred more frequently now. Physicians, to a certain extent, also take some responsibilities. Awareness of medical professionalism and its influence factors can be helpful to take targeted measures and alleviate the contradiction. Through a combination of physicians' self-assessment and patients' assessment in ambulatory care clinics in Chengdu, this research aims to evaluate the importance of medical professionalism in hospitals and explore the influence factors, hoping to provide decision-making references to improve this grim situation. From February to March, 2013, a cross-sectional study was conducted in 2 tier 3 hospitals, 5 tier 2 hospitals, and 10 community hospitals through a stratified-random sampling method on physicians and patients, at a ratio of 1/5. Questionnaires are adopted from a pilot study. A total of 382 physicians and 1910 patients were matched and surveyed. Regarding the medical professionalism, the scores of the self-assessment for physicians were 85.18 ± 7.267 out of 100 and the scores of patient-assessment were 57.66 ± 7.043 out of 70. The influence factors of self-assessment were physicians' working years (P = 0.003) and patients' complaints (P = 0.006), whereas the influence factors of patient-assessment were patients' ages (P = 0.001) and their physicians' working years (P < 0.01) and satisfaction on the payment mode (P = 0.006). Higher self-assessment on the medical professionalism was in accordance with physicians of more working years and no complaint history. Higher patient-assessment was in line with elder patients, the physicians' more working years, and higher satisfaction on the payment mode. Elder patients, encountering with physicians who worked more years in health care services or with higher satisfaction on the payment mode, contribute to higher scores in patient assessment part. The government should

  9. Equine wellness care in ambulatory practice.

    PubMed

    Sandoval, Claudia; True, Claudia

    2012-04-01

    Clients want dependable veterinary care and to understand how the services will benefit and meet their horse’s needs. Wellness visits provide ambulatory practitioners with great opportunities to strengthen the doctor-client-patient bond; effective communication with clients during wellness visits, where new literature or facts can be presented, can offer opportunities for demonstrating the value of having the veterinarian maintain a primary role in disease control. The criteria for selecting vaccines, interpreting FECs, and diagnosing dental pathology require the continued need for veterinary involvement. When providing wellness services, veterinarians should discuss those services, the reasons for them, as well as the possibility of adverse reactions. In so doing, the veterinarian is able to clearly distinguish himself or herself from a technician who is merely giving a "shot." Although some of these services can be performed by clients and lay professionals, the knowledge and training that veterinarians bring to these tasks add benefits to the horse beyond the services provided. For example, by targeting treatment and conveying the goals and limitations of FECs and deworming to clients, the speed at which anthelmintic resistance occurs will be diminished, and veterinarians will regain control over equine parasite management. Additional client education, such as demonstrating dental pathology to clients and how veterinary treatment benefits their horse, will not only improve the health of the horse further but also solidify the veterinarian’s role in preventative medicine. While all components of a wellness program were not detailed here, services such as nutritional consultation, blood work, and lameness evaluation should be offered based on the practice’s equine population. With the increasing population of geriatric horses, dentistry, nutrition, blood work, and lameness should be assessed annually or biannually. Each practice has its own set of criteria

  10. Impact of clinical preventive services in the ambulatory setting

    PubMed Central

    Ogola, Gerald; Mercer, Quay; Fong, Jaclyn; DeVol, Edward; Couch, Carl E.; Ballard, David J.

    2008-01-01

    Indicators of the performance of clinical preventive services (CPS) have been adopted in the ambulatory setting to improve quality of care. The impact of CPS was evaluated in a network of 49 primary care practices providing care to an estimated 245,000 adults in the Dallas–Fort Worth area through a sample chart review to determine delivery of recommended evidence-based CPS combined with medical literature estimates of the effectiveness of CPS. In this population in 2005, CPS were estimated to have prevented 36 deaths and 97 incident cases of cancer; 420 coronary heart disease events (including 66 sudden deaths) and 118 strokes; 816 cases of influenza and pneumonia (including 24 hospital admissions); and 87 osteoporosis-related fractures. Thus, CPS have substantial benefits in preventing deaths and illness episodes. PMID:18628969

  11. Opportunity costs of ambulatory medical care in the United States.

    PubMed

    Ray, Kristin N; Chari, Amalavoyal V; Engberg, John; Bertolet, Marnie; Mehrotra, Ateev

    2015-08-01

    The typical focus in discussions of healthcare spending is on direct medical costs such as physician reimbursement. The indirect costs of healthcare-patient opportunity costs associated with seeking care, for example-have not been adequately quantified. We aimed to quantify the opportunity costs for adults seeking medical care for themselves or others. Secondary analysis of the 2003-2010 American Time Use Survey (ATUS). We used the nationally representative 2003-2010 ATUS to estimate opportunity costs associated with ambulatory medical visits. We estimated opportunity costs for employed adults using self-reported hourly wages and for unemployed adults using a Heckman selection model. We used the Medical Expenditure Panel Survey to compare opportunity costs with direct costs (ie, patient out-of-pocket, provider reimbursement) in 2010. Average total time per visit was 121 minutes (95% CI, 118-124), with 37 minutes (95% CI, 36-39) of travel time and 84 minutes (95% CI, 81-86) of clinic time. The average opportunity cost per visit was $43, which exceeds the average patient's out-of-pocket payment. Total opportunity costs per year for all physician visits in the United States were $52 billion in 2010. For every dollar spent in visit reimbursement, an additional 15 cents were spent in opportunity costs. In the United States, opportunity costs associated with ambulatory medical care are substantial. Accounting for patient opportunity costs is important for examining US healthcare system efficiency and for evaluating methods to improve the efficient delivery of patient-centered care.

  12. Overview of Recent Literature on Undergraduate Ambulatory Care Education and a Framework for Future Planning.

    ERIC Educational Resources Information Center

    Yonke, Annette M.; Foley, Richard P.

    1991-01-01

    Ambulatory care undergraduate medical education from 1979-91 is examined and two major problems are found: (1) difficulties in transfer of educational techniques from hospital to ambulatory care setting; and (2) problems in definition of ambulatory care, primary care, and community-oriented primary care. A framework for planning education and…

  13. Blood Pressure Measurement: Clinic, Home, Ambulatory, and Beyond

    PubMed Central

    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

  14. An ambulatory care classification system: design, development and evaluation.

    PubMed Central

    Schneider, D

    1979-01-01

    A medical classification system for coding a patient's reason for visit has been developed for use in the National Ambulatory Medical Care Survey and for ambulatory care settings. The code is developed in a modular structure and includes modules for Symptoms; Diseases; Diagnostic, Screening and Preventive Procedures; Therapeutic Procedures, Process Problems and Counseling; Injuries and Adverse Effects; Follow-ups for Test Results; and Administrative Reasons for Visits. The system was evaluated in coding tests, through review by medical societies representing the major specialties, and by other health care providers. An extensive coding index is available. PMID:468555

  15. National Hospital Ambulatory Medical Care Survey: 1992 Emergency Department Summary.

    PubMed

    Schappert, S M

    1997-03-01

    This report presents data on the provision and utilization of ambulatory medical care services in hospital emergency departments during 1992. Ambulatory medical care services are described in terms of patient, visit, and facility characteristics. Among these are the patient's reason for the visit, diagnostic and screening services ordered or provided, diagnosis, and medications provided or prescribed. Cause of injury data are presented for injury-related visits. Data presented in this report are from the 1992 National Hospital Ambulatory Medical Care Survey (NHAMCS), a national survey of non-Federal, general and short-stay hospitals, conducted by the Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention. This report reflects the survey's first year of data collection. A four-stage probability sample design was used, resulting in a sample of 524 non-Federal, general and short-stay hospitals. Ninety-two percent of eligible facilities participated in the survey. Hospital staff were asked to complete Patient Record forms for a systematic random sample of patient visits occurring during a randomly assigned 4-week reporting period, and 36,271 forms were completed by participating emergency departments. Diagnosis and cause of injury were coded according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Reason for visit and medications were coded according to systems developed by the National Center for Health Statistics. An estimated 89.8 million visits were made to the emergency departments of non-Federal, general and short-stay hospitals in the United States during 1992-357.1 visits per 1,000 persons. Persons 75 years of age and over had a higher visit rate than persons in five other age categories. White persons accounted for 78.5 percent of all visits. However, the visit rate for black persons was significantly higher than for white persons overall and for

  16. Ambulatory care centers: structure, services, and marketing techniques.

    PubMed

    Phillips, J H; Reeder, C E

    1987-12-01

    A generic definition for an ambulatory care center (ACC) is not apparent. ACCs differ in ownership, primary function, and services offered. ACCs are attempting to expand their patient base by providing nonemergency care, contracting with provider organizations (e.g., HMOs and PPOs), and using aggressive marketing techniques.

  17. Teaching Interdisciplinary Geriatrics Ambulatory Care: A Case Study

    ERIC Educational Resources Information Center

    Williams, Brent C.; Remington, Tami L.; Foulk, Mariko A.; Whall, Ann L.

    2006-01-01

    Interdisciplinary health care training is advocated by numerous government and philanthropic organizations. Educators in the health professions are increasingly offering training in interdisciplinary health care in a variety of contexts, including ambulatory settings. This paper describes a three-year program to teach skills in interdisciplinary…

  18. Teaching Interdisciplinary Geriatrics Ambulatory Care: A Case Study

    ERIC Educational Resources Information Center

    Williams, Brent C.; Remington, Tami L.; Foulk, Mariko A.; Whall, Ann L.

    2006-01-01

    Interdisciplinary health care training is advocated by numerous government and philanthropic organizations. Educators in the health professions are increasingly offering training in interdisciplinary health care in a variety of contexts, including ambulatory settings. This paper describes a three-year program to teach skills in interdisciplinary…

  19. Impact of an Elective Course in Community and Ambulatory Care Pharmacy Practices on Student Perception of Patient Care

    PubMed Central

    Maguire, Michelle; Bennett, Marialice S.

    2015-01-01

    Objective. To determine the impact of an elective course on students’ perception of opportunities and of their preparedness for patient care in community and ambulatory pharmacy settings. Design. Each course meeting included a lecture and discussion to introduce concepts and active-learning activities to apply concepts to patient care or practice development in a community or ambulatory pharmacy setting. Assessment. A survey was administered to students before and after the course. Descriptive statistics were used to assess student responses to survey questions, and Wilcoxon signed rank tests were used to analyze the improvement in student responses with an alpha level set at 0.05. Students felt more prepared to provide patient care, develop or improve a clinical service, and effectively communicate recommendations to other health care providers after course completion. Conclusion. This elective course equipped students with the skills necessary to increase their confidence in providing patient care services in community and ambulatory settings. PMID:27168617

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

    PubMed

    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.

  1. Improving Ambulatory Care Resident Training: Preparing for Opportunities to Treat Mental Illness in the Primary Care Setting.

    PubMed

    Farhat, Nada M; Bostwick, Jolene R; Rockafellow, Stuart D

    2017-01-01

    The development of an outpatient psychiatry clinical practice learning experience for PGY2 ambulatory care pharmacy residents in preparation for the treatment of psychiatric disorders in the primary care setting is described. With the increased prevalence of psychiatric disorders, significant mortality, and limited access to care, integration of mental health treatment into the primary care setting is necessary to improve patient outcomes. Given the majority of mental health treatment occurs in the primary care setting, pharmacists in patient-centered medical homes (PCMHs) are in a unique position with direct access to patients to effectively manage these illnesses. However, the increased need for pharmacist education and training in psychiatry has prompted a large, Midwestern academic health system to develop an outpatient psychiatry learning experience for PGY2 (Postgraduate Year 2) ambulatory care pharmacy residents in 2015. The goal of this learning experience is to introduce the PGY2 ambulatory care residents to the role and impact of psychiatric clinical pharmacists and to orient the residents to the basics of psychiatric pharmacotherapy to be applied to their future practice in the primary care setting. The development of an outpatient psychiatry learning experience for PGY2 ambulatory care pharmacy residents will allow for more integrated and comprehensive care for patients with psychiatric conditions, many of whom are treated and managed in the PCMH setting.

  2. Improved Student Learning During Ambulatory Pediatric Clinical Clerkship

    ERIC Educational Resources Information Center

    Fosson, Abe; And Others

    1975-01-01

    In an effort to solve problems inherent to clinical clerkships, the faculty at the University of Kentuchy College of Medicine designed a project to identigy the core curriculum in ambulatory pediatrics consisting of 19 instructional packages. nAuthor/PG)

  3. Strategies for safe medication use in ambulatory care settings in the United States.

    PubMed

    Sorensen, Asta V; Bernard, Shulamit L

    2009-09-01

    This study aims to identify strategies for safe medication use practices in ambulatory care settings, with a special focus on clinical pharmacy services. We conducted case studies on 34 organizations, more than half of which were safety net providers. Data included discussions with 186 key informants, 3 interim debriefings, and a technical expert panel. We analyzed qualitative data using inductive analysis techniques and grounded theory approach. Ambulatory care organizations practice a broad range of safe medication use strategies. The inclusion of clinical pharmacy services is a culture change that supports efforts to improve patient safety and patient-centered care. Organizations integrated clinical pharmacy services when they introduced such services in a purposefully paced and gradual manner. Organizations sustained such services when they collected and reported data demonstrating improvements in patient outcomes and cost savings. Clinical pharmacy services were generally accompanied by strategies that helped organizations to provide patient-centered care; collect and measure process, safety, and clinical outcomes; promote leadership commitment; and integrate care delivery processes. These strategies interacted within organizations in synergistic rather than hierarchical or linear way. Organizational ability to provide safe, patient-centered, and efficient care that is supported by measurable data largely depends on leadership commitment and ability to integrate care processes. Ambulatory care organizations use multiple strategies for safe medication use systems. Understanding processes that promote such strategies will provide a helpful road map for other organizations in implementation and sustainability of safe medication use systems.

  4. Estimating annual charges for ambulatory care from limited utilization data.

    PubMed Central

    Saver, B G; Wagner, E H

    1995-01-01

    OBJECTIVE. This study explores the types of utilization information needed to produce a reasonable estimate of annual charges for ambulatory care that could be used in the absence of charge or cost data as an aggregate utilization measure. DATA SOURCE. Charge and utilization data from the RAND Health Insurance Experiment were used. STUDY DESIGN. Services provided to enrollees in the Health Insurance Experiment at each of the six sites for a one-year period were grouped into categories according to California Relative Value Studies (CRVS) codes. Using annual charges as the dependent variable, we evaluated linear regression models for their predictive accuracy, as indicated by adjusted R2-values. Categories of services were combined on the basis of clinical meaningfulness (e.g., all provider visits into one group), and predictive accuracy of models with these groupings of services examined. We examined model validity by applying the derived models to each of the 30 remaining site-years of data from the Health Insurance Experiment. PRINCIPAL FINDINGS. We were able to explain 84 percent of the variance in charges with a model containing counts of provider visits exclusive of mental health visits, mental health provider visits, days drugs were prescribed, days radiologic procedures were performed, procedural visits subdivided according to whether they were performed by a surgical or medical provider, days laboratory and/or pathology tests were performed, days a grouping of miscellaneous tests were performed, and days supplies were purchased. When applied to the validation data, this model predicted a mean of 77 percent of the variance and mean charges 102 +/- 9 percent of actual mean charges. A model with only the first four of the listed categories explained 77 percent of the variance in charges. CONCLUSIONS. Models using only counts of several broad categories of services perform rather well in predicting annual charges for ambulatory care. PMID:7860322

  5. The influence of distance on ambulatory care use, death, and readmission following a myocardial infarction.

    PubMed Central

    Piette, J D; Moos, R H

    1996-01-01

    OBJECTIVE: To examine whether patients admitted for treatment of a myocardial infarction (MI) who live farther from their source of care are less likely to be followed in an outpatient clinic, and whether patients who receive follow-up care are less likely to die or to have a subsequent acute care admission. DATA SOURCE: Department of Veterans Affairs (VA) databases to identify a national sample of 4,637 MI patients discharged in 1992, their use of care, and vital status within the subsequent year. Sociodemographics, comorbid diagnoses, invasive cardiac procedures, hospital teaching status, and distance to patients' admitting hospital were determined. STUDY DESIGN: Using these longitudinal data, we examined the relationship between patient characteristics, distance to care, and use of outpatient care after discharge. We then examined the relationship between the use of ambulatory care and subsequent death and readmission. PRINCIPAL FINDINGS: Patients living more than 20 miles from their admitting hospital were less likely to use ambulatory services. Patients receiving ambulatory care were 79 percent as likely to die within the year as those without any follow-up care (95% C.I. = 0.66, 0.94). Patients living more than 20 miles from their admitting hospital were more likely to die independent of their likelihood of receiving VA outpatient follow-up. Among patients who did not die in the subsequent year, those receiving ambulatory care were 33 percent more likely to be readmitted to a VA hospital with a cardiac diagnosis (95% C.I. = 1.12, 1.57). CONCLUSIONS: Distance may pose a barrier to outpatient follow-up for some VA patients after a MI. It also may limit patients' ability to access medical care quickly in the event of a recurrent acute event. Ambulatory care after discharge may be an important factor determining survival for patients with cardiac disease. PMID:8943991

  6. Method of evaluating and improving ambulatory medical care.

    PubMed Central

    Payne, B C; Lyons, T F; Neuhaus, E; Kolton, M; Dwarshius, L

    1984-01-01

    The usefulness of an action-research model is demonstrated in the evaluation and improvement of ambulatory medical care in a variety of settings: solo office practice, prepaid capitation multiple-specialty group practice, and medical school hospital-based outpatient clinic practice. Improvements in the process of medical care are found to relate directly to the intensity and duration of planned interventions by the study group and are demonstrated to follow organizational changes in the participating sites--primarily managerial and support services initiated by policy decisions in each study site. Improvement in performance approaching one standard deviation results from the most intense intervention, about one-half standard deviation at the next level of intervention, and virtually no change from a simple feedback of performance measures. On the basis of these findings and other operational and research efforts to improve physician performance, it is unlikely that simple feedback of performance measures will elicit a change in behavior. However, noncoercive methods involving health care providers in problem identification, problem solving, and solution implementation are demonstrated to be effective. PMID:6735736

  7. Clinical Assessment Applications of Ambulatory Biosensors

    ERIC Educational Resources Information Center

    Haynes, Stephen N.; Yoshioka, Dawn T.

    2007-01-01

    Ambulatory biosensor assessment includes a diverse set of rapidly developing and increasingly technologically sophisticated strategies to acquire minimally disruptive measures of physiological and motor variables of persons in their natural environments. Numerous studies have measured cardiovascular variables, physical activity, and biochemicals…

  8. Clinical Assessment Applications of Ambulatory Biosensors

    ERIC Educational Resources Information Center

    Haynes, Stephen N.; Yoshioka, Dawn T.

    2007-01-01

    Ambulatory biosensor assessment includes a diverse set of rapidly developing and increasingly technologically sophisticated strategies to acquire minimally disruptive measures of physiological and motor variables of persons in their natural environments. Numerous studies have measured cardiovascular variables, physical activity, and biochemicals…

  9. Hospitalization of older adults due to ambulatory care sensitive conditions

    PubMed Central

    Marques, Aline Pinto; Montilla, Dalia Elena Romero; de Almeida, Wanessa da Silva; de Andrade, Carla Lourenço Tavares

    2014-01-01

    OBJECTIVE To analyze the temporal evolution of the hospitalization of older adults due to ambulatory care sensitive conditions according to their structure, magnitude and causes. METHODS Cross-sectional study based on data from the Hospital Information System of the Brazilian Unified Health System and from the Primary Care Information System, referring to people aged 60 to 74 years living in the state of Rio de Janeiro, Souhteastern Brazil. The proportion and rate of hospitalizations due to ambulatory care sensitive conditions were calculated, both the global rate and, according to diagnoses, the most prevalent ones. The coverage of the Family Health Strategy and the number of medical consultations attended by older adults in primary care were estimated. To analyze the indicators’ impact on hospitalizations, a linear correlation test was used. RESULTS We found an intense reduction in hospitalizations due to ambulatory care sensitive conditions for all causes and age groups. Heart failure, cerebrovascular diseases and chronic obstructive pulmonary diseases concentrated 50.0% of the hospitalizations. Adults older than 69 years had a higher risk of hospitalization due to one of these causes. We observed a higher risk of hospitalization among men. A negative correlation was found between the hospitalizations and the indicators of access to primary care. CONCLUSIONS Primary healthcare in the state of Rio de Janeiro has been significantly impacting the hospital morbidity of the older population. Studies of hospitalizations due to ambulatory care sensitive conditions can aid the identification of the main causes that are sensitive to the intervention of the health services, in order to indicate which actions are more effective to reduce hospitalizations and to increase the population’s quality of life. PMID:25372173

  10. Accreditation Association for Ambulatory Health Care

    MedlinePlus

    ... Archives learn more » For Patients Your health care choices matter. Whether you're anticipating a surgical procedure, ... 853.9028 E: info@aaahc.org About Us Careers News & Resources Surveyors Find a Health Care Organization ...

  11. Interdisciplinary Shared Governance in Ambulatory Care: One Health System's Journey.

    PubMed

    Powers, Sharon; Bacon, Cynthia Thornton

    2016-01-01

    The implementation of shared governance structures in acute care has illustrated the positive relationship between shared decision making and nurse empowerment and positive nurse and patient outcomes. Little is known, however, about interdisciplinary shared governance, and even less is known about shared governance in ambulatory care. This article details one health system's experience with the implementation of an interdisciplinary shared governance structure in ambulatory care over a 4-year period. The authors report lessons learned, positive health system outcomes that resulted including improved communication, better preparedness for accreditation visits, improved assessment of fall risk, and a streamlined documentation system. Also discussed are mechanisms to enhance sustainability of the structure and discussion of future opportunities and challenges.

  12. Studies in the Delivery of Ambulatory Care.

    ERIC Educational Resources Information Center

    Kaplan, Robert; And Others

    A primary reason for increased government involvement in health care delivery resides in the acknowledged difficulty of the poor in obtaining adequate care. However, in the absence of knowledge about how health, health care, socio-economic status, race, ethnicity, and geographic location are related, policies aimed at implementing right to health…

  13. Ambulatory care centers: a unique opportunity for nurse practitioners.

    PubMed

    Henne, S J; Warner, N E; Frank, K J

    1988-10-01

    Nurse practitioners continue to struggle to find avenues for professional fulfillment. Urgent care or ambulatory care centers (ACCs) may, because of their need to respond to consumer demands for more comprehensive services, offer nurse practitioners a unique opportunity to establish productive primary care practices based on the concepts of total patient care. A model for such a practice has operated successfully since 1983, establishing that both professional and business success can result from the collaborative efforts of nurse practitioners and physicians in an ACC setting.

  14. [Evolution of the demand for ambulatory neurological care and pathologies attended in neurology clinics in the health care district of Tortosa, Tarragona].

    PubMed

    Huerta-Villanueva, M; Baiges-Octavio, J J; Martín-Ozaeta, G; Muñoz-Farjas, E; Rubio-Borrego, F

    An analysis was conducted to determine whether there were any changes in the demand for health care, demography and pathologies attended in outpatient departments within the health care district of Tortosa between 1997 and 2003. Data about the demand for and attendance at first neurology visits over the period 1997 and from March 2003 to February 2004 was collected prospectively. Information concerning age, sex, groups of pathologies, diagnoses, rates of requests for first visits, source of the demand and destination after the visit were compared. Mean age rose from 49 to 56 years (p < 0.001). Patients above 70 years of age increased from 23.7% to 35.9% (p < 0.001), while in the population within the area the figure only rose from 15.8 to 17.1%. The proportion of females went up from 52 to 62% (p < 0.001). Demand (that is, the rate of requests for first visits per 1000 inhabitants per year among those over the age of 15) rose from 8.5 to 9.3, 9.8% (p = 0.03). Demand from primary care increased from 52 to 69% (p < 0.001). Cognitive disorders (6.5% and 15.9%) grew by 144.6% (p < 0.001). Headaches (23.9% and 24.1%), the largest diagnostic group, and non-neurological diagnoses (18% and 18.5%) remained unchanged (p = NS). No changes were observed in the number of discharges in the first visit: 22.8% and 21.1% (p = NS). The most striking results are the increase in demand (mainly from primary care), the increased age of the population attended and the notable growth in the number of cognitive disorders. These quantitative and qualitative changes in the demand increase the need for resources.

  15. Describing Primary Care Encounters: The Primary Care Network Survey and the National Ambulatory Medical Care Survey

    PubMed Central

    Binns, Helen J.; Lanier, David; Pace, Wilson D.; Galliher, James M.; Ganiats, Theodore G.; Grey, Margaret; Ariza, Adolfo J.; Williams, Robert

    2007-01-01

    PURPOSE The purpose of this study was to describe clinical encounters in primary care research networks and compare them with those of the National Ambulatory Medical Care Survey (NAMCS). METHODS Twenty US primary care research networks collected data on clinicians and patient encounters using the Primary Care Network Survey (PRINS) Clinician Interview (PRINS-1) and Patient Record (PRINS-2), which were newly developed based on NAMCS tools. Clinicians completed a PRINS-1 about themselves and a PRINS-2 for each of 30 patient visits. Data included patient characteristics; reason for the visit, diagnoses, and services ordered or performed. We compared PRINS data with data obtained from primary care physicians during 5 cycles of NAMCS (1997–2001). Data were weighted; PRINS reflects participating networks and NAMCS provides national estimates. RESULTS By discipline, 89% of PRINS clinicians were physicians, 4% were physicians in residency training, 5% were advanced practice nurses/nurse-practitioners, and 2% were physician’s assistants. The majority (53%) specialized in pediatrics (34% specialized in family medicine, 9% in internal medicine, and 4% in other specialties). All NAMCS clinicians were physicians, with 20% specializing in pediatrics. When NAMCS and PRINS visits were compared, larger proportions of PRINS visits involved preventive care and were made by children, members of minority racial groups, and individuals who did not have private health insurance. A diagnostic or other assessment service was performed for 99% of PRINS visits and 76% of NAMCS visits (95% confidence interval, 74.9%–78.0%). A preventive or counseling/education service was provided at 64% of PRINS visits and 37% of NAMCS visits (95% confidence interval, 35.1%–38.0%). CONCLUSIONS PRINS presents a view of diverse primary care visits and differs from NAMCS in its methods and findings. Further examinations of PRINS data are needed to assess their usefulness for describing encounters that

  16. Trends in contraceptive and preconception care in United States ambulatory practices.

    PubMed

    Bello, Jennifer K; Rao, Goutham; Stulberg, Debra B

    2015-04-01

    Since 2005, the Centers for Disease Control and Prevention (CDC), American Academy of Family Physicians (AAFP), and American College of Obstetricians and Gynecologists (ACOG) have recommended incorporating family planning and preconception counseling into routine primary care visits. We compared rates of reproductive health service provision to women aged 15--44 years before and after these guidelines were issued and identified patient, physician, and visit characteristics associated with the likelihood of provision of preconception or contraceptive services. The National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected nationally representative data on provision of preconception and contraceptive services in 1998--2000 and 2009--2010. We used multivariable logistic regression with appropriate survey weights to assess changes over time in provision of these services, while controlling for patient demographics, medical comorbidities, and physician or clinic specialty. Among ambulatory encounters with women of reproductive age, provision of reproductive health services increased from 9.5% to 14% between 1998--2000 and 2009--2010, largely due to increased provision of prescription contraception. Despite CDC recommendations, a minority of ambulatory visits made by US women of reproductive age currently include either preconception or contraceptive services. Future work should focus on understanding barriers and developing interventions to facilitate incorporation of recommended services into primary care.

  17. Annotated Bibliography: Understanding Ambulatory Care Practices in the Context of Patient Safety and Quality Improvement.

    PubMed

    Montano, Maria F; Mehdi, Harshal; Nash, David B

    2016-11-01

    The ambulatory care setting is an increasingly important component of the patient safety conversation. Inpatient safety is the primary focus of the vast majority of safety research and interventions, but the ambulatory setting is actually where most medical care is administered. Recent attention has shifted toward examining ambulatory care in order to implement better health care quality and safety practices. This annotated bibliography was created to analyze and augment the current literature on ambulatory care practices with regard to patient safety and quality improvement. By providing a thorough examination of current practices, potential improvement strategies in ambulatory care health care settings can be suggested. A better understanding of the myriad factors that influence delivery of patient care will catalyze future health care system development and implementation in the ambulatory setting.

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

    PubMed

    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.

  19. Ambulatory Assessment of Depression in Primary Care

    DTIC Science & Technology

    2016-06-29

    effects on quality of life, such as perceived health , increased disability days, and higher rates of health care utilization (Spitzer et al., 1994; Ormel...depression in primary care settings greatly improves depressive symptoms, health -related functioning, and quality of life (Jackson, DeZee, & Berbano...depressive symptom severity. After 12 months follow-up, the treatment group also reported improved social functioning and general health perception

  20. Developing ambulatory care registered nurse competencies for care coordination and transition management.

    PubMed

    Haas, Sheila; Swan, Beth Ann; Haynes, Traci

    2013-01-01

    The need for care coordination and management of transitions between Patient-Centered Medical Home providers, outpatient and community settings, including the Accountable Care Organization is often overlooked, episodic, and accountability for coordinating care and managing transitions between providers and services is lacking. Recognizing the potential of the RN to contribute to enhanced quality, cost effectiveness, and access to care in ambulatory settings, the Board of Directors of the American Academy of Ambulatory Care Nursing (AAACN) created a care coordination competencies action plan with three phases to delineate RN competencies and develop an education program for care coordination and transition management in ambulatory care. The first Expert Panel completed a comprehensive, interdisciplinary literature review and analysis focused on care coordination and transition management. The second Expert Panel--representing nu rsing, medicine, and pharmacy--defined the dimensions, identified core competencies, and described the activities linked with each competency for care coordination and transition management in ambulatory settings. The third Expert Panel reviewed, confirmed, and created a table of dimensions, activities, and competencies (including knowledge, skills, attitudes) for ambulatory care RN care coordination and transition management.

  1. The role of the nurse in an ambulatory stroke and cognition clinic.

    PubMed

    Flogen, BettyAnn R; Stern, Bianca; Wagner, Laura M

    2006-01-01

    In this paper we described our approach to the development of the role of a nurse within a stroke and cognition ambulatory clinic at Baycrest. In developing this approach we integrated Baycrest's commitment to clients and family-focused care, our focus on interdisciplinary collaborative practice, the position of the post-rehabilitation clinic in the continuum of care, the clinical experience of the nurse and director, and the relevant scholarly literature. The role of the nurses in the stroke and cognition clinic includes assessment, interdisciplinary care planning, client/family support, and knowledge transfer.

  2. A Portable Computer System for Auditing Quality of Ambulatory Care

    PubMed Central

    McCoy, J. Michael; Dunn, Earl V.; Borgiel, Alexander E.

    1987-01-01

    Prior efforts to effectively and efficiently audit quality of ambulatory care based on comprehensive process criteria have been limited largely by the complexity and cost of data abstraction and management. Over the years, several demonstration projects have generated large sets of process criteria and mapping systems for evaluating quality of care, but these paper-based approaches have been impractical to implement on a routine basis. Recognizing that portable microcomputers could solve many of the technical problems in abstracting data from medical records, we built upon previously described criteria and developed a microcomputer-based abstracting system that facilitates reliable and cost-effective data abstraction.

  3. Using trigger phrases to detect adverse drug reactions in ambulatory care notes

    PubMed Central

    Cantor, Michael N; Feldman, Henry J; Triola, Marc M

    2007-01-01

    Background As medical care moves towards an outpatient focus, monitoring systems for ambulatory patients are increasingly important. Because adverse outcomes due to medications are an important problem in outpatients, the authors developed an automated monitoring system for detecting adverse drug reactions (ADRs) in ambulatory patients. Methods The authors obtained a set of approximately 110 000 ambulatory care notes from the medicine clinic at Bellevue Hospital Centre for 2003–4, and manually analysed a representative sample of 1250 notes to obtain a gold standard. To detect ADRs in the text of electronic ambulatory notes, the authors used a “trigger phrases” methodology, based on a simple grammar populated with a limited set of keywords. Results Under current functionality, this system detected 38 of 54 cases in the authors' gold standard set, of which 17 were true positives, for a sensitivity of 31%, a specificity of 98%, and a positive predictive value of 45%. Their proxy measure correlated with 70% of the ADRs in the gold standard. These values are comparable or superior to other systems described in the literature. Conclusions These results show that an automated system can detect ADRs with moderate sensitivity and high specificity, and has the potential to serve as the basis for a larger scale reporting system. PMID:17403760

  4. The emerging role of cell phone technology in ambulatory care.

    PubMed

    Boland, Peter

    2007-01-01

    Three factors are coinciding to reshape the ambulatory care market: chronic disease prevalence, workforce shortages, and the availability of cell phone technology with very high consumer penetration. These factors will disproportionately drive the business strategies and practices of ambulatory care providers, payers, and delivery systems this decade. Market dynamics are driving the healthcare industry to adopt new strategies to deal with the swelling prevalence of chronic disease. Healthcare organizations are constrained by money and inadequate tools to systematically manage chronic care patients. As a result, traditional notions of ambulatory care are changing from being provider-centered to becoming more patient-centric. A host of new remote monitoring and communication technologies are available so that providers can now interact with patients "anywhere, anytime." The traditional care setting is shifting to where the patient is rather than where the physician is located. Patients are the most underutilized resource in healthcare, and patient engagement is the key to managing chronic illness. Cell phones are particularly suited for leveraging the time and expertise of providers while engaging patients in their own self-care. To demonstrate this concept, data are presented that illustrate how cell phone applications significantly reduced the cost of treating severely asthmatic children and teens in 2 ways: through more frequent communication between patients and their medical teams, and by motivating patients to become more engaged and knowledgeable about their care. The healthcare industry can support consumer choice by making available as many options as possible for engaging patients in their care. Consumers like having choices and patients are no different: they are not all one type. This suggests an emerging role for cell phone applications and platforms that enable both Internet and medical device connectivity where appropriate for managing chronic

  5. Regional variations in ambulatory care and incidence of cardiovascular events.

    PubMed

    Tu, Jack V; Chu, Anna; Maclagan, Laura; Austin, Peter C; Johnston, Sharon; Ko, Dennis T; Cheung, Ingrid; Atzema, Clare L; Booth, Gillian L; Bhatia, R Sacha; Lee, Douglas S; Jackevicius, Cynthia A; Kapral, Moira K; Tu, Karen; Wijeysundera, Harindra C; Alter, David A; Udell, Jacob A; Manuel, Douglas G; Mondal, Prosanta; Hogg, William

    2017-04-03

    Variations in the prevalence of traditional cardiac risk factors only partially account for geographic variations in the incidence of cardiovascular disease. We examined the extent to which preventive ambulatory health care services contribute to geographic variations in cardiovascular event rates. We conducted a cohort study involving 5.5 million patients aged 40 to 79 years in Ontario, Canada, with no hospital stays for cardiovascular disease as of January 2008, through linkage of multiple population-based health databases. The primary outcome was the occurrence of a major cardiovascular event (myocardial infarction, stroke or cardiovascular-related death) over the following 5 years. We compared patient demographics, cardiac risk factors and ambulatory health care services across the province's 14 health service regions, known as Local Health Integration Networks (LHINs), and evaluated the contribution of these variables to regional variations in cardiovascular event rates. Cardiovascular event rates across LHINs varied from 3.2 to 5.7 events per 1000 person-years. Compared with residents of high-rate LHINs, those of low-rate health regions received physician services more often (e.g., 4.2 v. 3.5 mean annual family physician visits, p value for LHIN-level trend = 0.01) and were screened for risk factors more often. Low-rate LHINs were also more likely to achieve treatment targets for hypercholes-terolemia (51.8% v. 49.6% of patients, p = 0.03) and controlled hypertension (67.4% v. 53.3%, p = 0.04). Differences in patient and health system factors accounted for 74.5% of the variation in events between LHINs, of which 15.5% was attributable to health system factors alone. Preventive ambulatory health care services were provided more frequently in health regions with lower cardiovascular event rates. Health system interventions to improve equitable access to preventive care might improve cardiovascular outcomes. © 2017 Canadian Medical Association or its licensors.

  6. Regional variations in ambulatory care and incidence of cardiovascular events

    PubMed Central

    Tu, Jack V.; Chu, Anna; Maclagan, Laura; Austin, Peter C.; Johnston, Sharon; Ko, Dennis T.; Cheung, Ingrid; Atzema, Clare L.; Booth, Gillian L.; Bhatia, R. Sacha; Lee, Douglas S.; Jackevicius, Cynthia A.; Kapral, Moira K.; Tu, Karen; Wijeysundera, Harindra C.; Alter, David A.; Udell, Jacob A.; Manuel, Douglas G.; Mondal, Prosanta; Hogg, William

    2017-01-01

    BACKGROUND: Variations in the prevalence of traditional cardiac risk factors only partially account for geographic variations in the incidence of cardiovascular disease. We examined the extent to which preventive ambulatory health care services contribute to geographic variations in cardiovascular event rates. METHODS: We conducted a cohort study involving 5.5 million patients aged 40 to 79 years in Ontario, Canada, with no hospital stays for cardiovascular disease as of January 2008, through linkage of multiple population-based health databases. The primary outcome was the occurrence of a major cardiovascular event (myocardial infarction, stroke or cardiovascular-related death) over the following 5 years. We compared patient demographics, cardiac risk factors and ambulatory health care services across the province’s 14 health service regions, known as Local Health Integration Networks (LHINs), and evaluated the contribution of these variables to regional variations in cardiovascular event rates. RESULTS: Cardiovascular event rates across LHINs varied from 3.2 to 5.7 events per 1000 person-years. Compared with residents of high-rate LHINs, those of low-rate health regions received physician services more often (e.g., 4.2 v. 3.5 mean annual family physician visits, p value for LHIN-level trend = 0.01) and were screened for risk factors more often. Low-rate LHINs were also more likely to achieve treatment targets for hypercholes-terolemia (51.8% v. 49.6% of patients, p = 0.03) and controlled hypertension (67.4% v. 53.3%, p = 0.04). Differences in patient and health system factors accounted for 74.5% of the variation in events between LHINs, of which 15.5% was attributable to health system factors alone. INTERPRETATION: Preventive ambulatory health care services were provided more frequently in health regions with lower cardiovascular event rates. Health system interventions to improve equitable access to preventive care might improve cardiovascular outcomes. PMID

  7. Assessing Diabetes Care Disparities with Ambulatory Care Quality Measures

    PubMed Central

    Joseph, Jennifer M; Johnson, Pamela Jo; Wholey, Douglas R; Frederick, Mary L

    2015-01-01

    Objective To identify and describe racial/ethnic disparities in overall diabetes management. Data Source/Study Setting Electronic health record data from calendar year 2010 were obtained from all primary care clinics at one large health system in Minnesota (n = 22,633). Study Design We used multivariate logistic regression to estimate the odds of achieving the following diabetes management goals: A1C <8 percent, LDL cholesterol <100 mg/dl, blood pressure <140/90 mmHg, tobacco-free, and daily aspirin. Principal Findings Blacks and American Indians have higher odds of not achieving all goals compared to whites. Disparities in specific goals were also found. Conclusions Although this health system has above-average diabetes care quality, significant disparities by race/ethnicity were identified. This underscores the importance of stratifying quality measures to improve care and outcomes for all. PMID:25523494

  8. Use of hospital-based ambulatory care in New York City's Health Manpower Shortage Areas.

    PubMed Central

    Stager, D F; Krasner, M I; Goodwin, E J

    1987-01-01

    The development of a comprehensive data base for hospital-based ambulatory care has made possible the accurate determination of each community's use of hospitals in New York City and permits a reliable estimation of all ambulatory care received by residents of Health Manpower Shortage Areas (HMSAs). In spite of the city's abundant supply of private practitioners and widespread Medicaid coverage, residents of HMSAs in New York City are heavily dependent on hospital-based ambulatory care. Contrary to commonly held notions, however, HMSA residents do not appear to overuse hospital-based ambulatory care. Rather, that use appears to be quite modest, given their poorer health status. PMID:3101118

  9. Ambulatory Blood Pressure Monitoring in Clinical Practice: A Review

    PubMed Central

    Viera, Anthony J.; Shimbo, Daichi

    2016-01-01

    Ambulatory blood pressure monitoring offers the ability to collect blood pressure readings several times an hour across a 24-hour period. Ambulatory blood pressure monitoring facilitates the identification of white-coat hypertension, the phenomenon whereby certain individuals who are not on antihypertensive medication show elevated blood pressure in a clinical setting but show non-elevated blood pressure averages when assessed by ambulatory blood pressure monitoring. Additionally, readings can be segmented into time windows of particular interest, e.g., mean daytime and nighttime values. During sleep, blood pressure typically decreases, or dips, such that mean sleep blood pressure is lower than mean awake blood pressure. A non-dipping pattern and nocturnal hypertension are strongly associated with increased cardiovascular morbidity and mortality. Approximately 70% of individuals dip ≥10% at night, while 30% have non-dipping patterns, when blood pressure remains similar to daytime average, or occasionally rises above daytime average. The various blood pressure categorizations afforded by ambulatory blood pressure monitoring are valuable for clinical management of high blood pressure since they increase accuracy for diagnosis and the prediction of cardiovascular risk. PMID:25107387

  10. [The first ambulatory clinic for the prevention of women's cancer: the Strang clinic of New York].

    PubMed

    Alonso de Ruiz, Patricia; Ruiz Moreno, José Antonio

    2013-01-01

    The first ambulatory clinic for the prevention of women's cancers was the Strang clinic of New York City, founded by L'Esperance in 1932. Careful and complete clinical examination and some additional tests were the basis for the initial diagnosis of early cancers. In 1945, the Papanicolaou test was added as a new examination tool. Some years later, the Strang clinic proved that detection and treatment of cervical cancers in their preinvasive phase were an important factor for the control of this frequent and mortal neoplasia. The Strang clinic demonstrated that the preventive medicine principles can be applied on the discovery and diagnosis of initial cancer cases and that the treatment applied in such cases offers the best results. Additionally, according with these results, the early diagnosis and treatment of cancers should be the work's philosophy applied in all the health systems.

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

    PubMed

    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.

  12. The costs of a family practice residency ambulatory care program.

    PubMed

    Pawlson, L G; Watkins, R

    1979-12-01

    The cost of patient care service and education occurring in a family practice residency unit of a community based prepaid health program was determined from accounting records. The cost of producing the same number of patient visits in comparable family practice units which did not have residents on-site was determined in a similar manner. The cost per visit in the residency unit was $15.53 while that in the nonresidency unit was $13.92. There was an excess cost of $1.61 per visit in the residency, or, based on the number of residents present, a net cost of $7 per resident per day. None of the costs of central residency program administration or of ambulatory based subspecialty rotations were included. While a small increase (ten percent) in productivity or efficiency would result in the residency patient care unit itself being self-sustaining, this study casts considerable doubt on the ability of the model family practice residency unit to offset the full costs of the ambulatory care portion of family practice residency training.

  13. Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review

    PubMed Central

    Martin-Misener, Ruth; Harbman, Patricia; Donald, Faith; Reid, Kim; Kilpatrick, Kelley; Carter, Nancy; Bryant-Lukosius, Denise; Kaasalainen, Sharon; Marshall, Deborah A; Charbonneau-Smith, Renee; DiCenso, Alba

    2015-01-01

    Objective To determine the cost-effectiveness of nurse practitioners delivering primary and specialised ambulatory care. Design A systematic review of randomised controlled trials reported since 1980. Data sources 10 electronic bibliographic databases, handsearches, contact with authors, bibliographies and websites. Included studies Randomised controlled trials that evaluated nurse practitioners in alternative and complementary ambulatory care roles and reported health system outcomes. Results 11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: −€6.41; 95% CI −€9.28 to −€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly. Conclusions Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider

  14. Organization of ambulatory care provision: a critical determinant of health system performance in developing countries.

    PubMed

    Berman, P

    2000-01-01

    Success in the provision of ambulatory personal health services, i.e. providing individuals with treatment for acute illness and preventive health care on an ambulatory basis, is the most significant contributor to the health care system's performance in most developing countries. Ambulatory personal health care has the potential to contribute the largest immediate gains in health status in populations, especially for the poor. At present, such health care accounts for the largest share of the total health expenditure in most lower income countries. It frequently comprises the largest share of the financial burden on households associated with health care consumption, which is typically regressively distributed. The "organization" of ambulatory personal health services is a critical determinant of the health system's performance which, at present, is poorly understood and insufficiently considered in policies and programmes for reforming health care systems. This article begins with a brief analysis of the importance of ambulatory care in the overall health system performance and this is followed by a summary of the inadequate global data on ambulatory care organization. It then defines the concept of "macro organization of health care" at a system level. Outlined also is a framework for analysing the organization of health care services and the major pathways through which the organization of ambulatory personal health care services can affect system performance. Examples of recent policy interventions to influence primary care organization--both government and nongovernmental providers and market structure--are reviewed. It is argued that the characteristics of health care markets in developing countries and of most primary care goods result in relatively diverse and competitive environments for ambulatory care services, compared with other types of health care. Therefore, governments will be required to use a variety of approaches beyond direct public provision

  15. Organization of ambulatory care provision: a critical determinant of health system performance in developing countries.

    PubMed Central

    Berman, P.

    2000-01-01

    Success in the provision of ambulatory personal health services, i.e. providing individuals with treatment for acute illness and preventive health care on an ambulatory basis, is the most significant contributor to the health care system's performance in most developing countries. Ambulatory personal health care has the potential to contribute the largest immediate gains in health status in populations, especially for the poor. At present, such health care accounts for the largest share of the total health expenditure in most lower income countries. It frequently comprises the largest share of the financial burden on households associated with health care consumption, which is typically regressively distributed. The "organization" of ambulatory personal health services is a critical determinant of the health system's performance which, at present, is poorly understood and insufficiently considered in policies and programmes for reforming health care systems. This article begins with a brief analysis of the importance of ambulatory care in the overall health system performance and this is followed by a summary of the inadequate global data on ambulatory care organization. It then defines the concept of "macro organization of health care" at a system level. Outlined also is a framework for analysing the organization of health care services and the major pathways through which the organization of ambulatory personal health care services can affect system performance. Examples of recent policy interventions to influence primary care organization--both government and nongovernmental providers and market structure--are reviewed. It is argued that the characteristics of health care markets in developing countries and of most primary care goods result in relatively diverse and competitive environments for ambulatory care services, compared with other types of health care. Therefore, governments will be required to use a variety of approaches beyond direct public provision

  16. Ambulatory care provision versus first admission to psychiatric hospital: 5 years follow up.

    PubMed

    Robin, Michaël; Bronchard, Marion; Kannas, Serge

    2008-06-01

    in the number of days of hospitalisation. From the second year onwards, the use of hospitalisation did not seem to be influenced by the type of care initially given to the patient. Rehospitalisation was rare in both groups. One third of the patients in the experimental group benefited from another intervention of the ambulatory emergency team from the second year onwards, highlighting the value placed on this type of care by the patients and their families. Our results support the development of ambulatory crisis intervention services, including those from psychiatric hospitals. Clinical studies following the treatment paths of patients in a more exhaustive manner would almost certainly distinguish more precisely between the "natural" course of the disease and the impact of the care provided. In any case, the prevention of hospitalisation must be based as much on a possible alternative at the time of the crisis as on subsequent access to ambulatory care.

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

    PubMed Central

    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.

  18. [Current clinical aspects of ambulatory blood pressure monitoring].

    PubMed

    Sauza-Sosa, Julio César; Cuéllar-Álvarez, José; Villegas-Herrera, Karla Montserrat; Sierra-Galán, Lilia Mercedes

    2016-01-01

    Systemic arterial hypertension is the prevalentest disease worldwide that significantly increases cardiovascular risk. An early diagnosis together to achieve goals decreases the risk of complications significatly. Recently have been updated the diagnostic criteria for hypertension and the introduction of ambulatory blood pressure monitoring. The introduction into clinical practice of ambulatory blood pressure monitoring was to assist the diagnosis of «white coat hypertension» and «masked hypertension». Today has also shown that ambulatory blood pressure monitoring is better than the traditional method of recording blood pressure in the office, to the diagnosis and to adequate control and adjustment of drug treatment. Also there have been introduced important new concepts such as isloted nocturnal hypertension, morning blood pressure elevation altered and altered patterns of nocturnal dip in blood pressure; which have been associated with increased cardiovascular risk. Several studies have shown significant prognostic value in some stocks. There are still other concepts on which further study is needed to properly establish their introduction to clinical practice as hypertensive load variability, pulse pressure and arterial stiffness. In addition to setting values according to further clinical studies in populations such as elderly and children.

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

    PubMed

    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.

  20. Pediatric Chest Pain-Low-Probability Referral: A Multi-Institutional Analysis From Standardized Clinical Assessment and Management Plans (SCAMPs®), the Pediatric Health Information Systems Database, and the National Ambulatory Medical Care Survey.

    PubMed

    Harahsheh, Ashraf S; O'Byrne, Michael L; Pastor, Bill; Graham, Dionne A; Fulton, David R

    2017-11-01

    We conducted a study to assess test characteristics of red-flag criteria for identifying cardiac disease causing chest pain and technical charges of low-probability referrals. Accuracy of red-flag criteria was ascertained through study of chest pain Standardized Clinical Assessment and Management Plans (SCAMPs®) data. Patients were divided into 2 groups: Group1 (concerning clinical elements) and Group2 (without). We compared incidence of cardiac disease causing chest pain between these 2 groups. Technical charges of Group 2 were analyzed using the Pediatric Health Information System database. Potential savings for the US population was estimated using National Ambulatory Medical Care Survey data. Fifty-two percent of subjects formed Group 1. Cardiac disease causing chest pain was identified in 8/1656 (0.48%). No heart disease was identified in patients in Group 2 ( P = .03). Applying red-flags in determining need for referral identified patients with cardiac disease causing chest pain with 100% sensitivity. Median technical charges for Group 2, over a 4-year period, were US2014$775 559. Eliminating cardiac testing of low-probability referrals would save US2014$3 775 182 in technical charges annually. Red-flag criteria were an effective screen for children with chest pain. Eliminating cardiac testing in children without red-flags for referral has significant technical charge savings.

  1. Private Physicians in Ambulatory Care Training in U.S. Medical Schools.

    ERIC Educational Resources Information Center

    Meadows, John C., Jr.; And Others

    1986-01-01

    The contribution of private physicians to medical student education in ambulatory care was determined by a questionnaire directed to departments of family practice, internal medicine, and pediatrics in U.S. medical schools. Departments of family practice were most likely to offer ambulatory care courses. (Author/MLW)

  2. Needle phobia--changing venepuncture practice in ambulatory care.

    PubMed

    Thurgate, Claire; Heppell, Sue

    2005-11-01

    Needle phobia is a term used in practice to describe an anticipatory fear of needle insertion. A proportion of children display high levels of fear, pain and behavioural distress when exposed to, or anticipating, needle insertion. A difficult routine venepuncture in our ambulatory care unit led staff to review practice and develop a three-step approach to overcoming 'needle phobia': relaxation, control and graded exposure. These developments have resulted in the unit becoming a local referral centre for children and young people between the ages of 5-19 years with this problem. Time and skill are needed to prevent or overcome this distressing problem which can be caused by health care professionals not listening to children and young people.

  3. [Essential hypertension in young people--ambulatory versus hospital care].

    PubMed

    Mitu, F; Leon, Maria-Magdalena

    2012-01-01

    Cardiovascular disease is the leading cause of death in our country. The number of young people with hypertension grow up quickly, so a good control of dyslipidemia and blood pressure (BP) is essential in prevention of cardiovascular disease. To investigate the prevalence of HTA at young people and established the corelation with another risk factors like smoke, colesterol, obesity and heredity, few data are available on the blood pressure characteristics of young patients. It has been investigate 366 young people between 19-25 years old, in ambulatory system and 350 younger with the same age, in hospital. Blood pressure was measured according to standard procedures, and was considered well-controlled if it was < 140/90 mm Hg. From our ambulatory patients were 198 women (54.1%), 168 men (45.9%) and from hospital were 178 women (50.9%) and 172 men (41.9%). HTA was present at 37 patients (10.1%) in ambulatory system and 50 patients (14.3%) in hospital. Between the intensity of smoke, the number of cigarette and the prevalence of HTA is a direct relation. The heredity factor is very important, too. The prevalence grow more than 2.5 at this patients. The incidence of HTA is 1.9 bigger at women with big values of colesterol and 2.1 at men with big colesterol. The relation between HTA--obesity is proven in our study, the incidence of HTA is 2.6 bigger at the obeses patients. These arguments should also promote further research in primary care on the control and the therapeutic behavior of the physicians.

  4. [New technological equipments and their economical impact in ambulatory care].

    PubMed

    Levy, F; Doan, B D

    1993-01-01

    The 1st Part of the study, based on 3 opinion surveys among ambulatory care providers (French physicians in private practice) shows a steady increase of prescribed technological "acts". However, the number of physicians having high-tech devices in their office is much lower. Ownership is understandably less frequent than equipment leasing or renting. In the French context, turnover of physicians for using high-tech equipment is outpaced by turnover of patients: as a rule, general practitioners send their patients to the specialist's offices or to hospitals (in France, the specialists practice both in ambulatory and institutional settings). The 2nd Part of the study, based on 4,471 physicians' tax files, attempts to identify the investment behavior of doctors in private practice regarding new technological devices. The specialty and the obsolescence speed of the equipment play both an important role. However, the choice between renting/leasing and purchasing depends also whether the doctor has a long run or a short term perspective. Such a choice is clearly evidenced through the French mechanisms of income taxation. It explains why the doctor's annual income (gross or net) is not significantly related to his investment behavior.

  5. Benzodiazepine Prescribing in Older Adults in U.S. Ambulatory Clinics and Emergency Departments (2001-10).

    PubMed

    Marra, Erin M; Mazer-Amirshahi, Maryann; Brooks, Gillian; van den Anker, John; May, Larissa; Pines, Jesse M

    2015-10-01

    To assess trends in benzodiazepine use from 2001 to 2010 in older adults in U.S. ambulatory clinics and emergency departments (EDs). Retrospective analysis. 2001 to 2010 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Individuals aged 65 and older for whom the reason for visit might prompt a physician to use a benzodiazepine (e.g., anxiety, detoxification, back sprain). The NAMCS and NHAMCS were used to evaluate U.S. ambulatory clinic and ED visits. Encounters involving individuals aged 65 and older for whom a benzodiazepine might be prescribed were analyzed. Trends in benzodiazepine use in these visits were explored, and predictors of use were assessed using survey-weighted chi-square tests and logistic regression. From 2001 to 2010, benzodiazepines were used in 16.6 million of 133.3 million ambulatory clinic visits and 1.9 million of 18.1 million ED visits with the selected reasons for the visits. There was no change in benzodiazepine use in either setting over the study period, although benzodiazepine use for those aged 85 and older increased from 8.9% to 19.3% in ambulatory clinics and 10.1% to 17.2% in EDs. Individuals visiting clinics with anxiety were five times as likely to receive benzodiazepines (odds ratio (OR) = 4.8), and those in EDs were twice as likely (OR = 2.3). Despite safety concerns, benzodiazepine use in older adults in U.S. ambulatory clinics and EDs did not change from 2001 to 2010. In the oldest individuals, who are at higher risk of adverse events, a greater increase was seen than in those aged 65 to 84. Additional measures may be needed to promote alternatives to benzodiazepines. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

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

    PubMed

    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.

  7. Fatigue in the acute care and ambulatory setting.

    PubMed

    McCabe, Margaret; Patricia, Branowicki

    2014-01-01

    Nurses commonly assess their patients for symptoms and intervene to ease any patient distress, yet children are seldom asked about feeling fatigued. The existing pediatric literature suggests that fatigue goes unrecognized and therefore untreated in children, particularly children experiencing stressful events, such as illness and/or hospitalization. In an effort to better understand the presence of the symptom in our environment we conducted a program specific point prevalence survey. Data were collected on nine inpatient and 11 outpatient units of a university affiliated tertiary care children's hospital. Overall, this sample reported higher levels of fatigue than published data from their healthy and chronically ill peers by total fatigue score and sub scores. This brief description of the symptom in our inpatient and ambulatory settings has provided information that will inform our nursing practice and drive future research. Copyright © 2014 Elsevier Inc. All rights reserved.

  8. Development and application of a population-oriented measure of ambulatory care case-mix.

    PubMed

    Weiner, J P; Starfield, B H; Steinwachs, D M; Mumford, L M

    1991-05-01

    This article describes a new case-mix methodology applicable primarily to the ambulatory care sector. The Ambulatory Care Group (ACG) system provides a conceptually simple, statistically valid, and clinically relevant measure useful in predicting the utilization of ambulatory health services within a particular population group. ACGs are based on a person's demographic characteristics and their pattern of disease over an extended period of time, such as a year. Specifically, the ACG system is driven by a person's age, sex, and ICD-9-CM diagnoses assigned during patient-provider encounters; it does not require any special data beyond those collected routinely by insurance claims systems or encounter forms. The categorization scheme does not depend on the presence of specific diagnoses that may change over time; rather it is based on broad clusters of diagnoses and conditions. The presence or absence of each disease cluster, along with age and sex, are used to classify a person into one of 51 ACG categories. The ACG system has been developed and tested using computerized encounter and claims data from more than 160,000 continuous enrollees at four large HMOs and a state's Medicaid program. The ACG system can explain more than 50% of the variance in ambulatory resource use if used retrospectively and more than 20% if applied prospectively. This compares with 6% when age and sex alone are used. In addition to describing ACG development and validation, this article also explores some potential applications of the system for provider payment, quality assurance, utilization review, and health services research, particularly as it relates to capitated settings.

  9. Errors in Completion of Referrals among Urban Older Adults in Ambulatory Care

    PubMed Central

    Weiner, Michael; Perkins, Anthony J.; Callahan, Christopher M.

    2015-01-01

    RATIONALE, AIMS, AND OBJECTIVES Clinical care often requires referrals, but many referrals never result in completed evaluations. We determined the extent to which referral-based consultations were completed in a U.S. medical institution. Factors associated with completion were identified. METHOD In cross-sectional analysis, we analyzed billing records and electronic and paper-based medical records, for patients 65 or more years of age receiving healthcare between July 2000 and June 2002 in an integrated, urban, tax-supported medical institution on an academic campus. All referrals in ambulatory care, scheduling of consultation within 180 days, and completion were assessed. We conducted multivariate survival analysis to identify factors associated with completion. RESULTS We identified 6,785 patients with encounters. Mean age was 72 years, with 66% women, 55% African-American, and 32% Medicaid-eligible. Of 81% with at least one primary-care visit in ambulatory care, 63% had at least one referral. About 8% of referrals required multiple orders before an appointment was scheduled. Among 7,819 orders for specialty consultation in ambulatory care, 71% led to appointments, and 70% of appointments were kept (completed = 0.71*0.70 or 50%). Scheduling of consultations varied (12% to 90%) by specialty. Medicare, singular orders, location of referral, and lack of hospitalization were independently significantly associated scheduling of appointments. CONCLUSIONS Among older adults studied, half of medical specialty referrals were not completed. Multiple process errors likely contribute to these results, including missing information, misguided referrals, and faulty communications. Information systems offer important opportunities to improve the referrals process. PMID:20367818

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

    MedlinePlus

    ... member of your health care team. The “Speak Up” program is sponsored by The Joint Commission. They ... health care mistakes, patients are urged to “Speak Up.” S peak up if you have questions or concerns. ...

  11. What Ambulatory Care Managers Need to Know About Examination Room Utilization Measurement and Analysis.

    PubMed

    Klarich, Mark J; Rea, Ronald W; Lal, Tarun Mohan; Garcia, Angel L; Steffens, Fay L

    2016-01-01

    Demand for ambulatory care visits is projected to increase 22% between 2008 and 2025. Given this growth, ambulatory care managers need to proactively plan for efficient use of scarce resources (ie, space, equipment, and staff). One important component of ambulatory care space (the number of examination rooms) is dependent on multiple factors, including variation in demand, hours of operation, scheduling, and staff. The authors (1) outline common data collection methods, (2) highlight analysis and reporting considerations for examination room utilization, and (3) provide a strategic framework for short- and long-term decision making for facility design or renovation.

  12. Evaluation of a career ladder program in an ambulatory care environment.

    PubMed

    Nelson, Joan M; Cook, Paul F

    2008-01-01

    Clinical ladders, or career advancement systems, were designed to enhance professional development, provide a reward system for quality clinical performance, promote quality nursing practice, and improve job satisfaction among nurses. Most of the literature on RN clinical ladder programs is related to the acute care setting, where these programs originated; not much is known about their effectiveness in the ambulatory care environment. The RN Career Ladder at Kaiser Permanente of Colorado was begun by a Labor Management Partnership Committee in 2003, and awards financial incentives to RNs who demonstrate a commitment to continuing education, leadership activities, and program development on a local and regional level. In this study significantly more involvement in leadership, interdisciplinary, and quality improvement activities were found among career ladder nurses than non-career ladder nurses, regardless of their job role. It is not clear whether nursing leaders gravitate toward a career ladder or whether career ladder participation encourages increased participation in leadership activities.

  13. A break-even analysis of optimum faculty assignment for ambulatory primary care training.

    PubMed

    Xakellis, G C; Gjerde, C L; Xakellis, M G; Klitgaard, D

    1996-12-01

    The increased demand that faculty teach residents in ambulatory clinics necessitates the development of ambulatory care teaching models that are both educationally effective and financially viable. This study was designed to identify the resident-to-faculty ratios needed to provide financially viable faculty supervision of residents while maintaining acceptable resident waiting times for teaching. A computer simulation was developed to estimate the number of residents one or two faculty teachers could supervise in a university-based primary care teaching clinic. The number of residents was calculated for three waiting-time constraints and three scenarios of faculty tasks. A financial analysis of each model was performed. With no non-teaching tasks, two teachers were able to supervise 11 residents and keep waiting times under two minutes, while one teacher was able to supervise only three residents with this waiting-time constraint. The financial break-even point was achieved by all of the two-teacher models, but by none of the one-teacher models. In all three scenarios, using two teachers resulted in more than double the number of residents supervised and in higher utilization of faculty time (higher productivity) than did using one teacher. The two-teacher models of ambulatory supervision allowed for sufficient numbers of residents to be supervised so that teaching costs could be covered from patient care revenues; the one-teacher models did not break even financially. These simulations offer a viable option for academic institutions that are struggling to maintain teaching quality in the face of financial constraints.

  14. Ambulatory care training during core internal medicine residency training: the Canadian experience.

    PubMed Central

    McLeod, P J; Meagher, T W

    1993-01-01

    OBJECTIVE: To determine the status of ambulatory care training of core internal medicine residents in Canada. DESIGN: Mail survey. PARTICIPANTS: All 16 program directors of internal medicine residency training programs in Canada. OUTCOME MEASURES: The nature and amount of ambulatory care training experienced by residents, information about the faculty tutors, and the sources and types of patients seen by the residents. As well, the program directors were asked for their opinions on the ideal ambulatory care program and the kinds of teaching skills required of tutors. RESULTS: All of the directors responded. Fifteen stated that the ambulatory care program is mandatory, and the other stated that it is an elective. Block rotations are more common than continuity-of-care assignments. In 12 of the programs 10% or less of the overall training time is spent in ambulatory care. In 11 the faculty tutors comprise a mixture of generalists and subspecialists. The tutors simultaneously care for patients and teach residents in the ambulatory care setting in 14 of the schools. Most are paid through fee-for-service billing. The respondents felt that the ideal program should contain a mix of general and subspecialty ambulatory care training. There was no consensus on whether it should be a block or continuity-of-care experience, but the directors felt that consultation and communication skills should be emphasized regardless of which type of experience prevails. CONCLUSIONS: Although there is a widespread commitment to provide core internal medicine residents with experience in ambulatory care, there is little uniformity in how this is achieved in Canadian training programs. PMID:8324688

  15. Clinic Function and Computerized Ambulatory Records: A Concurrent Study with Conventional Records

    PubMed Central

    Campbell, James R.; Givner, Nathaniel; Seelig, Charles B.; Patil, Kashinath; Wigton, Robert S.; Tape, Thomas G.

    1988-01-01

    Controlled studies of computerized ambulatory information systems are rare. As part of an evaluation of the effects of COSTAR on clinic function, we divided our resident teaching clinic into a study group with access to COSTAR and a control group allowed access only to conventional medical records. We sampled staff attitudes toward use of the computer and did detailed time studies of clinic patient flow. Staff attitudes reflected a high degree of acceptance, favoring COSTAR over conventional records. This was primarily related to improvement in telephone management and demand care. House staff never became facile users of COSTAR because of infrequent clinic sessions. Clinics assigned to COSTAR experienced somewhat longer waiting times due to an increased workload and training effects. Installation of computerized records should prompt a careful evaluation of expected benefits.

  16. [Health care contract, economic options and budgeting in ambulatory care].

    PubMed

    Richter-Reichhelm, M

    2000-12-01

    At the beginning the principle of profitability (sufficient, suitable, economical, necessary) and its effects on medical action are analysed. An explanation is given why the appointed doctors cannot provide medical care satisfactorily in a budgeted system under mere economical criteria. The budget leads to rationing and quality reduction and leaves no scope for medical progress. The instruments for the observance of profitability (profitability examination and guidelines) are dealt with critically. Another instrument, the department budgets, which were introduced by the Social Democrat--Green government, is rejected as a mere economically calculated control mechanism with regard to health care. As a further budget the restrictive medication and curative budgets are presented. They involve the danger of payment exclusions, whereby the high quality care is called into question, if the doctor does not want to suffer a loss of fees. Alternatively, standard values with individual examination are suggested instead of the budgets with collective regress.

  17. Health information exchange in the wild: the association between organizational capability and perceived utility of clinical event notifications in ambulatory and community care.

    PubMed

    Vest, Joshua R; Ancker, Jessica S

    2017-01-01

    Event notifications are real-time, electronic, automatic alerts to providers of their patients' health care encounters at other facilities. Our objective was to examine the effects of organizational capability and related social/organizational issues upon users' perceptions of the impact of event notifications on quality, efficiency, and satisfaction. We surveyed representatives (n = 49) of 10 organizations subscribing to the Bronx Regional Health Information Organization's event notification services about organizational capabilities, notification information quality, perceived usage, perceived impact, and organizational and respondent characteristics. The response rate was 89%. Average item scores were used to create an individual domain summary score. The association between the impact of event notifications and organizational characteristics was modeled using random-intercept logistic regression models. Respondents estimated that organizations followed up on the majority (83%) of event notifications. Supportive organizational policies were associated with the perception that event notifications improved quality of care (odds ratio [OR] = 2.12; 95% CI, = 1.05, 4.45), efficiency (OR = 2.06; 95% CI = 1.00, 4.21), and patient satisfaction (OR = 2.56; 95% CI = 1.13, 5.81). Higher quality of event notification information was also associated with a perceived positive impact on quality of care (OR = 2.84; 95% CI = 1.31, 6.12), efficiency (OR = 3.04; 95% CI = 1.38, 6.69), and patient satisfaction (OR = 2.96; 95% CI = 1.25, 7.03). Health care organizations with appropriate processes, workflows, and staff may be better positioned to use event notifications. Additionally, information quality remains critical in users' assessments and perceptions. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  18. Electronic results management in pediatric ambulatory care: qualitative assessment.

    PubMed

    Ferris, Timothy G; Johnson, Sarah A; Co, John Patrick T; Backus, Meghan; Perrin, James; Bates, David W; Poon, Eric G

    2009-01-01

    Electronic results management may improve the reliability and efficiency of test results management, but few studies have investigated this topic in pediatrics. We conducted semi-structured, key informant interviews before and after implementation of electronic results management at 8 pediatric ambulatory care practices. We also surveyed all pediatricians at 18 practices (10 additional practices). All practices were members of Partners Healthcare and had been using an electronic health record when they were offered electronic results management. We assessed baseline processes for results management, barriers to electronic results management adoption, and the perceived impact of electronic results management on quality, efficiency, and provider satisfaction. From interviews, we found a range of processes in place to manage test results, but all practices reported losing some results and no practice tracked all test results from the time of ordering to parent/patient notification. Practices that fully adopted electronic results management reported gains in efficiency, reliability, timeliness, and provider satisfaction, whereas some partial adopters reported decreased efficiency and increased risk of lost test results. Barriers to electronic results management adoption included lack of inclusion of all ordered tests in the electronic results management system, user interface design issues, and lack of sufficient pediatric customization. Survey results (response rate: 62%) indicated that pediatricians thought electronic results management improved the quality and efficiency of care, with 72% of pediatricians reporting safer care and 63% reporting more-effective care. We found that pediatric practices have room for improvement in the management of test results, and electronic results management may be an effective method for improving the efficiency and safety of test results management. However, partial adoption of electronic results management may decrease efficiency

  19. Adopting ambulatory breast cancer surgery as the standard of care in an asian population.

    PubMed

    Ng, Yvonne Ying Ru; Chan, Patrick Mun Yew; Chen, Juliana Jia Chuan; Seah, Melanie Dee Wern; Teo, Christine; Tan, Ern Yu

    2014-01-01

    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.

  20. The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care

    PubMed Central

    Reddy, Ashok; Pollack, Craig E.; Asch, David A.; Canamucio, Anne; Werner, Rachel M.

    2017-01-01

    IMPORTANCE Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. OBJECTIVE To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. DESIGN, SETTING, AND PARTICIPANTS Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326 374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184 501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. EXPOSURES Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). MAIN OUTCOMES AND MEASURES Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). RESULTS Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, −5.3; 95% CI, −6.0 to −4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, −1.1; 95% CI, −2.1 to −0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, −1.44; 95

  1. The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care.

    PubMed

    Reddy, Ashok; Pollack, Craig E; Asch, David A; Canamucio, Anne; Werner, Rachel M

    2015-07-01

    Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326,374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184,501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, -5.3; 95% CI, -6.0 to -4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, -1.1; 95% CI, -2.1 to -0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, -1.44; 95% CI, -2.2 to -0.7). In 9 measures of ambulatory care quality, the difference between patients who experienced no

  2. Development of a new patient-based measure of pediatric ambulatory care.

    PubMed

    Gallagher, Patricia; Ding, Lin; Ham, Hazen P; Schor, Edward L; Hays, Ron D; Cleary, Paul D

    2009-11-01

    In 1995, the Agency for Health Care Policy and Research initiated the Consumer Assessments of Healthcare Providers and Systems (CAHPS) project to develop and evaluate survey protocols for collecting reliable and valid assessments of health care from consumers. CAHPS surveys are used throughout the United States for evaluating ambulatory and hospital care experiences, including a version for assessing pediatric ambulatory care; however, pediatric experts thought that the existing pediatric instruments did not adequately assess developmental and preventive care. The objective of this study was to develop and test an Ambulatory Pediatric CAHPS survey that focuses on clinicians and groups and includes measures of developmental and preventive care. To develop the survey, we conducted 2 focus groups and conducted 9 cognitive interviews. We conducted a telephone pretest with 20 parents and coded potential problems with the interview (behavioral coding). We conducted a dual-language field test of the instrument with 670 parents who reported about their children's ambulatory care. We used data from that survey to assess the reliability and validity of the measures. Questions about developmental monitoring and preventive care were developed and tested. Two scales that were based on those new questions had good internal consistency (coefficient alpha) and inter-physician reliability. A consortium of CAHPS investigators and federal sponsors have approved the resulting instrument as a national measure of pediatric care. A new instrument for assessing ambulatory pediatric care by clinicians and groups that includes questions about developmental and preventive care is now available for use.

  3. Development of a New Patient-Based Measure of Pediatric Ambulatory Care

    PubMed Central

    Gallagher, Patricia; Ding, Lin; Ham, Hazen P.; Schor, Edward L.; Hays, Ron D.; Cleary, Paul D.

    2017-01-01

    OBJECTIVE In 1995, the Agency for Health Care Policy and Research initiated the Consumer Assessments of Healthcare Providers and Systems (CAHPS) project to develop and evaluate survey protocols for collecting reliable and valid assessments of health care from consumers. CAHPS surveys are used throughout the United States for evaluating ambulatory and hospital care experiences, including a version for assessing pediatric ambulatory care; however, pediatric experts thought that the existing pediatric instruments did not adequately assess developmental and preventive care. The objective of this study was to develop and test an Ambulatory Pediatric CAHPS survey that focuses on clinicians and groups and includes measures of developmental and preventive care. METHODS To develop the survey, we conducted 2 focus groups and conducted 9 cognitive interviews. We conducted a telephone pretest with 20 parents and coded potential problems with the interview (behavioral coding). We conducted a dual-language field test of the instrument with 670 parents who reported about their children’s ambulatory care. We used data from that survey to assess the reliability and validity of the measures. RESULTS Questions about developmental monitoring and preventive care were developed and tested. Two scales that were based on those new questions had good internal consistency (coefficient α) and interphysician reliability. A consortium of CAHPS investigators and federal sponsors have approved the resulting instrument as a national measure of pediatric care. CONCLUSIONS A new instrument for assessing ambulatory pediatric care by clinicians and groups that includes questions about developmental and preventive care is now available for use. PMID:19822587

  4. Psychometric analysis of the ambulatory care learning education environment measure (ACLEEM) in Iran.

    PubMed

    Naghizadeh Moogari, Zahra; Koohpayehzadeh, Jalil; Roff, Susanne; Montazeri, Ali; Soltani Arabshahi, Seyyed Kamran; Bigdeli, Shoaleh; Moosavi, Maryam; Azaminejad, Faranak; Tavousi, Mahmoud

    2015-01-01

    Examining educational environment (academic and clinical) by means of a valid, reliable and comprehensive questionnaire is a major key in achieving a highly qualified student - oriented curricula. The Persian translation of Ambulatory Care Learning Education Environment Measure-ACLEEM questionnaire has been developed to support this goal, and its psychometrics has been explored in this administration in teaching hospitals affiliated to Tehran University of Medical Sciences. This descriptive - analytical study involved medical residents in four major clinics. In this study, the ACLEEM Questionnaire was conducted after translating and retranslating the questionnaire and examine the face and content validity, construct validity, test retest reliability and internal consistency coefficient. In this study, 157 out of 192 residents completed the questionnaire (response rate 82%). The mean age of the residents was 31.81 years .The final mean of the questionnaire was calculated as 110.91 out of 200 (with 95% confidence interval). Test - retest stability of the questionnaire was between 0.322 and 0.968. The face validity of the questionnaire was confirmed. The content validity ratio was 0.64; and content validity Index was 0.78. In Exploratory factor analysis, eight factors were confirmatory that changed the orientation of some questions. The Cronbach's alpha coefficient of the whole questionnaire was 0.936. According to the data, the Persian version of the ACLEEM questionnaire has sufficient psychometric reliability and validity to be used for conducting research, teaching and practicing the educational learning environment in ambulatory care in Iran.

  5. Medication literacy status of outpatients in ambulatory care settings in Changsha, China.

    PubMed

    Zheng, Feng; Ding, Siqing; Luo, Aijing; Zhong, Zhuqing; Duan, Yinglong; Shen, Zhiying

    2017-02-01

    Objective To assess medication literacy status and to examine risk factors of inadequate medication literacy of outpatients in ambulatory care settings. Methods Study participants were recruited randomly from outpatient departments in four tertiary hospitals (Xiangya Hospital of Central South University, Second Xiangya Hospital of Central South University, Third Xiangya Hospital of Central South University, People's Hospital of Hunan Province) in Changsha, Hunan, China, between October 2014 and January 2015. Medication literacy was assessed using the Medication Literacy Scale, Chinese version. Demographic and clinical data were collected using structured interviews. Multiple logistic regression analysis was used to estimate the independent effects of demographic and clinical factors on medication literacy. Results Of 465 participants, 425 (91.4%) produced valid responses for analysis. The mean medication literacy score was 8.31 (standard deviation = 3.47). Medication literacy was adequate in 131 participants (30.8%), marginally adequate in 248 (58.4%), and inadequate in 46 (10.8%). The risk of inadequate medication literacy was greater for older and unmarried patients but lower for more educated patients. Conclusion Many Chinese outpatients in ambulatory care have inadequate medication literacy. Greater age, low education, and unmarried status are important risk factors of inadequate medication literacy.

  6. Indicators for Evaluating the Performance and Quality of Care of Ambulatory Care Nurses.

    PubMed

    Rapin, Joachim; D'Amour, Danielle; Dubois, Carl-Ardy

    2015-01-01

    The quality and safety of nursing care vary from one service to another. We have only very limited information on the quality and safety of nursing care in outpatient settings, an expanding area of practice. Our aim in this study was to make available, from the scientific literature, indicators potentially sensitive to nursing that can be used to evaluate the performance of nursing care in outpatient settings and to integrate those indicators into the theoretical framework of Dubois et al. (2013). We conducted a scoping review in three databases (CINAHL, MEDLINE, and EMBASE) and the bibliographies of selected articles. From a total of 116 articles, we selected 22. The results of our study not only enable that framework to be extended to ambulatory nursing care but also enhance it with the addition of five new indicators. Our work offers nurses and managers in ambulatory nursing units indicators potentially sensitive to nursing that can be used to evaluate performance. For researchers, it presents the current state of knowledge on this construct and a framework with theoretical foundations for future research in ambulatory settings. This work opens an unexplored field for further research.

  7. Indicators for Evaluating the Performance and Quality of Care of Ambulatory Care Nurses

    PubMed Central

    Rapin, Joachim; D'Amour, Danielle; Dubois, Carl-Ardy

    2015-01-01

    The quality and safety of nursing care vary from one service to another. We have only very limited information on the quality and safety of nursing care in outpatient settings, an expanding area of practice. Our aim in this study was to make available, from the scientific literature, indicators potentially sensitive to nursing that can be used to evaluate the performance of nursing care in outpatient settings and to integrate those indicators into the theoretical framework of Dubois et al. (2013). We conducted a scoping review in three databases (CINAHL, MEDLINE, and EMBASE) and the bibliographies of selected articles. From a total of 116 articles, we selected 22. The results of our study not only enable that framework to be extended to ambulatory nursing care but also enhance it with the addition of five new indicators. Our work offers nurses and managers in ambulatory nursing units indicators potentially sensitive to nursing that can be used to evaluate performance. For researchers, it presents the current state of knowledge on this construct and a framework with theoretical foundations for future research in ambulatory settings. This work opens an unexplored field for further research. PMID:26380108

  8. Ibuprofen timing for hand surgery in ambulatory care.

    PubMed

    Giuliani, Enrico; Bianchi, Anna; Marcuzzi, Augusto; Landi, Antonio; Barbieri, Alberto

    2015-01-01

    To evaluate the effect of pre-operative administration of ibuprofen on post-operative pain control vs. early post-operative administration for hand surgery procedures performed under local anaesthesia in ambulatory care. Candidates to trigger finger release by De Quervain tenosynovitis and carpal tunnel operation under local anesthesia were enrolled in the study. Group A received 400 mg ibuprofen before the operation and placebo after the procedure; group B received placebo before the operation and ibuprofen 400 mg at the end of the procedure; both groups received ibuprofen 400 mg every 6h thereafter. Visual analogue scale (VAS) was measured at fixed times before and every 6h after surgery, for a total follow-up of 18h. Groups were similar according to age, gender and type of surgery. Median VAS values did not produce any statistical significance, while there was a statistically significant difference on pre-operative and early post-operative VAS values between groups (A -8.53 mm vs. B 3.36 mm, p=0.0085). Average pain levels were well controlled by local anesthesia and post-operative ibuprofen analgesia. Pre-operative ibuprofen administration can contribute to improve early pain management. Level of Evidence II, Therapeutic Studies.

  9. Ibuprofen timing for hand surgery in ambulatory care

    PubMed Central

    Giuliani, Enrico; Bianchi, Anna; Marcuzzi, Augusto; Landi, Antonio; Barbieri, Alberto

    2015-01-01

    OBJECTIVE: To evaluate the effect of pre-operative administration of ibuprofen on post-operative pain control vs. early post-operative administration for hand surgery procedures performed under local anaesthesia in ambulatory care. METHODS: Candidates to trigger finger release by De Quervain tenosynovitis and carpal tunnel operation under local anesthesia were enrolled in the study. Group A received 400 mg ibuprofen before the operation and placebo after the procedure; group B received placebo before the operation and ibuprofen 400 mg at the end of the procedure; both groups received ibuprofen 400 mg every 6h thereafter. Visual analogue scale (VAS) was measured at fixed times before and every 6h after surgery, for a total follow-up of 18h. RESULTS: Groups were similar according to age, gender and type of surgery. Median VAS values did not produce any statistical significance, while there was a statistically significant difference on pre-operative and early post-operative VAS values between groups (A -8.53 mm vs. B 3.36 mm, p=0.0085). CONCLUSION: Average pain levels were well controlled by local anesthesia and post-operative ibuprofen analgesia. Pre-operative ibuprofen administration can contribute to improve early pain management. Level of Evidence II, Therapeutic Studies. PMID:26327799

  10. Clinic Design and Continuity in Internal Medicine Resident Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative

    PubMed Central

    Francis, Maureen D.; Wieland, Mark L.; Drake, Sean; Gwisdalla, Keri Lyn; Julian, Katherine A.; Nabors, Christopher; Pereira, Anne; Rosenblum, Michael; Smith, Amy; Sweet, David; Thomas, Kris; Varney, Andrew; Warm, Eric; Wininger, David; Francis, Mark L.

    2015-01-01

    Background Many internal medicine (IM) programs have reorganized their resident continuity clinics to improve trainees' ambulatory experience. Downstream effects on continuity of care and other clinical and educational metrics are unclear. Methods This multi-institutional, cross-sectional study included 713 IM residents from 12 programs. Continuity was measured using the usual provider of care method (UPC) and the continuity for physician method (PHY). Three clinic models (traditional, block, and combination) were compared using analysis of covariance. Multivariable linear regression analysis was used to analyze the effect of practice metrics and clinic model on continuity. Results UPC, reflecting continuity from the patient perspective, was significantly different, and was highest in the block model, midrange in combination model, and lowest in the traditional model programs. PHY, reflecting continuity from the perspective of the resident provider, was significantly lower in the block model than in combination and traditional programs. Panel size, ambulatory workload, utilization, number of clinics attended in the study period, and clinic model together accounted for 62% of the variation found in UPC and 26% of the variation found in PHY. Conclusions Clinic model appeared to have a significant effect on continuity measured from both the patient and resident perspectives. Continuity requires balance between provider availability and demand for services. Optimizing this balance to maximize resident education, and the health of the population served, will require consideration of relevant local factors and priorities in addition to the clinic model. PMID:26217420

  11. Clinic Design and Continuity in Internal Medicine Resident Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative.

    PubMed

    Francis, Maureen D; Wieland, Mark L; Drake, Sean; Gwisdalla, Keri Lyn; Julian, Katherine A; Nabors, Christopher; Pereira, Anne; Rosenblum, Michael; Smith, Amy; Sweet, David; Thomas, Kris; Varney, Andrew; Warm, Eric; Wininger, David; Francis, Mark L

    2015-03-01

    Many internal medicine (IM) programs have reorganized their resident continuity clinics to improve trainees' ambulatory experience. Downstream effects on continuity of care and other clinical and educational metrics are unclear. This multi-institutional, cross-sectional study included 713 IM residents from 12 programs. Continuity was measured using the usual provider of care method (UPC) and the continuity for physician method (PHY). Three clinic models (traditional, block, and combination) were compared using analysis of covariance. Multivariable linear regression analysis was used to analyze the effect of practice metrics and clinic model on continuity. UPC, reflecting continuity from the patient perspective, was significantly different, and was highest in the block model, midrange in combination model, and lowest in the traditional model programs. PHY, reflecting continuity from the perspective of the resident provider, was significantly lower in the block model than in combination and traditional programs. Panel size, ambulatory workload, utilization, number of clinics attended in the study period, and clinic model together accounted for 62% of the variation found in UPC and 26% of the variation found in PHY. Clinic model appeared to have a significant effect on continuity measured from both the patient and resident perspectives. Continuity requires balance between provider availability and demand for services. Optimizing this balance to maximize resident education, and the health of the population served, will require consideration of relevant local factors and priorities in addition to the clinic model.

  12. Students' time allocation in a required third-year ambulatory care clerkship.

    PubMed

    Lawrence, S L; Mark, D H; Fulkerson, P K; Cohen, R

    1994-01-01

    To assess time use by students during clinic sessions of an ambulatory care clerkship. All 207 third-year students at the Medical College of Wisconsin during 1991-92 were asked to report their time use in eight categories during two clinic sessions of the three-week clinical component of the required clerkship in ambulatory care medicine. Other variables assessed were site of clinical rotation, first versus third week of rotation, and time of year of rotation. The statistical methods used were t-tests and one-way analysis of variance. Of the 207 students, 192 (93%) completed time-allocation reports for the first and third weeks of their rotations. The average time spent per clinic session was four hours. Compared with the students at faculty practice sites, the students at private practice sites spent significantly more time observing and working with preceptors as they saw patients and significantly less time doing solo clinical work (reviewing and writing in charts). During the course of each rotation, the students increased the time they saw patients by themselves and decreased the time they observed preceptors. As the year progressed, later cohorts of students spent less time observing preceptors and more time working by themselves. Both within and across rotations, the students eventually spent less time observing and more time working independently. However, the results suggest that preceptors in private practice may not allow students as much autonomy as do faculty preceptors. Further research is needed to determine (1) whether the differences between types of preceptors result in meaningful differences in the quality of education and (2) which activities or mixes of activities contribute most to students' education.

  13. Worksite Physical Activity Intervention for Ambulatory Clinic Nursing Staff.

    PubMed

    Tucker, Sharon; Farrington, Michele; Lanningham-Foster, Lorraine M; Clark, M Kathleen; Dawson, Cindy; Quinn, Geralyn J; Laffoon, Trudy; Perkhounkova, Yelena

    2016-07-01

    Health behaviors, including physical activity (PA), of registered nurses (RNs) and medical assistants (MAs) are suboptimal but may improve with worksite programs. Using a repeated-measures crossover design, the authors explored if integrating a 6-month worksite non-exercise activity thermogenesis (NEAT) intervention, with and without personalized health coaching via text messaging into workflow could positively affect sedentary time, PA, and body composition of nursing staff without jeopardizing work productivity. Two ambulatory clinics were randomly assigned to an environmental NEAT intervention plus a mobile text message coaching for either the first 3 months (early texting group, n = 27) or the last 3 months (delayed texting group, n = 13), with baseline 3-month and 6-month measurements. Sedentary and PA levels, fat mass, and weight improved for both groups, significantly only for the early text group. Productivity did not decline for either group. This worksite intervention is feasible and may benefit nursing staff. © 2016 The Author(s).

  14. Ambulatory Care Sensitive Conditions in Persons with an Intellectual Disability--Development of a Consensus

    ERIC Educational Resources Information Center

    Balogh, Robert S.; Ouellette-Kuntz, Helene; Brownell, Marni; Colantonio, Angela

    2011-01-01

    Background: There is evidence that the primary care provided for persons with an intellectual disability living in the community has been inadequate. Hospitalization rates for ambulatory care sensitive (ACS) conditions are considered an indicator for access to, and quality of, primary care. The objective of this research was to identify ACS…

  15. Ambulatory Care Sensitive Conditions in Persons with an Intellectual Disability--Development of a Consensus

    ERIC Educational Resources Information Center

    Balogh, Robert S.; Ouellette-Kuntz, Helene; Brownell, Marni; Colantonio, Angela

    2011-01-01

    Background: There is evidence that the primary care provided for persons with an intellectual disability living in the community has been inadequate. Hospitalization rates for ambulatory care sensitive (ACS) conditions are considered an indicator for access to, and quality of, primary care. The objective of this research was to identify ACS…

  16. On the interdependence of ambulatory and hospital care in the German health system.

    PubMed

    Büyükdurmus, Tugba; Kopetsch, Thomas; Schmitz, Hendrik; Tauchmann, Harald

    2017-12-01

    For some considerable time now the interface between ambulatory and hospital care has been mooted as a cause of inefficiencies in the German health system and there have been calls for a softening of the strict separation between the two sectors. This debate emphasizes the need for detailed empirical information on the interdependence between the two sectors. Using extensive administrative data at the level of the 412 German counties for the years 2007 to 2009 and a simultaneous equation model which allows the numbers of ambulatory and hospital cases to be mutually interdependent, we examine the connection between ambulatory and hospital specialist care separately for ten medical specialties. The results show that the interdependence of ambulatory and hospital services is far from homogeneous. The relationship depends, on the one hand, on the specialty and, on the other, on the direction of the effect observed. This heterogeneity needs to be taken into account for cross-sector needs-based planning.

  17. The case for a code of ethics in an ambulatory care setting.

    PubMed

    Montoya, I D; Richard, A J

    1995-07-01

    The health care industry leads others in the development and use of professional codes of ethics. However, ambulatory care facilities continue to operate without coherent ethical guidelines addressing the workplace itself. New diagnostic and treatment capabilities, coupled with economic pressures, have intensified the ethical dilemmas facing the ambulatory care practice. This article argues that office codes of ethics decrease the risk of liability exposure, clarify the expectations of patients and staff, and foster responsible ethical reflection in the workplace. Material for this article was gathered from relevant literature in the areas of business ethics, bioethics, and health care management.

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

    PubMed

    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.

  19. New concepts and technologies in home care and ambulatory monitoring.

    PubMed

    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

  20. Characteristics of chronic arthritis and other rheumatic condition-related ambulatory care visits, united states, 1997.

    PubMed

    Hootman; Helmick; Schappert

    2000-10-01

    PURPOSE: To characterize ambulatory medical care visits among persons with arthritis and other rheumatic conditions, the leading cause of disability.METHODS: The 1997 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) collect annual data on the utilization of ambulatory medical services provided by non-federal office-based physicians and hospital outpatient and emergency departments. Arthritis-related visits were defined using a predetermined set of ICD9-CM diagnostic codes developed by an expert panel and designed to include all potential diagnoses for arthritis and other rheumatic conditions. Visits related to acute conditions such as injuries were not included. National estimates and rates of arthritis-related ambulatory care visits were calculated by age, race, and sex groups.RESULTS: In 1997, there were an estimated 959.3 million ambulatory care visits, of which over 38 million (4.0%) were related to arthritis and other rheumatic conditions. Arthritis-related visits were more likely to be made by females (65.4%), white persons (82.2%), non-Hispanic persons (72.7%) and persons aged 25-64 years (61.9%). More than one-third of arthritis-related visits were for osteoarthritis, rheumatoid arthritis and unspecified myalgia/myositis. About half (50.2%) of the office visits for arthritis were made to general/family physicians or internists, while an additional 16.2% were to rheumatologists. Counseling or education related to exercise, diet/nutrition and injury prevention were provided at 18.9%, 9.2% and 2.2% of office and outpatient department visits respectively.CONCLUSIONS: Arthritis and other rheumatic conditions are common conditions associated with ambulatory medical care. These results suggest missed opportunities for counseling patients regarding public health prevention messages for arthritis, including increasing moderate physical activity, weight management and injury prevention.

  1. A comparison of economic aspects of hospitalization versus ambulatory care in the management of neuritis occurring in lepra reaction.

    PubMed

    H N, Ravi; George, Renu; Eapen, Elizabeth P; Pulimood, Susanne A; Gnanamuthu, Chandran; Jacob, Mary; John, K R

    2004-12-01

    Neuritis is one of the important causes of deformities and disabilities in leprosy. Neuritis has been managed both in the field and in hospital. This study was done to compare the economic aspects of cost of ambulatory vs in-patient management of neuritis in leprosy. The quality of life of the affected patients and the clinical improvement in the 2 groups were also studied. Twenty six patients fulfilling the study criteria were randomized into the ambulatory and in-patient group (13 in each group). The primary outcome examined was cost, in various categories; the secondary outcomes included pre- and post-treatment comparison of Quality of Life (QOL) scores and tests of sensory and motor function. The direct and indirect medical costs incurred by patients in the hospitalized group were higher than those patients in the ambulatory group. The difference in the direct medical costs between the two groups was Rs. 9110.5, and the extra direct non medical costs incurred by patients in the hospitalized group was Rs. 888.50 because of more frequent visits of family members. A greater percentage of ambulatory than in-patients returned to work in ambulatory patients compared to 66.8 days for in-patients group. The QOL scores and motor and sensory function tests showed no significant difference between groups. Although the sample size was small, these preliminary results suggest that substantial cost minimization by ambulatory care is possible without significantly affecting the quality of life or peripheral nerve function.

  2. [Taking care of the caregiver: evaluation of the degree of satisfaction, stress levels and expectations of caregivers of patients attending an ambulatory unit for Alzheimer disease evaluation].

    PubMed

    Marabotto, Marco; Raspo, Silvio; Gerardo, Bruno; Cena, Paola; Bonetto, Martina; Cappa, Giorgetta

    2011-04-01

    According to literature, challenges associated with caregiving of demented should be taken into great consideration. The aim of the present study was to evaluate the knowledge about dementia and health services dedicated to demented care among the caregivers of the patients attending our Dementia Ambulatory, caregivers' level of autonomy in taking care of the demented patients, their levels of stress and the degree of their satisfaction as the services provided by our Dementia Ambulatory. Our data show how a memory clinic needs to take care of both patients and their caregivers, with particular stress on caregiver specific education and well-being.

  3. Hospitalizations for ambulatory care sensitive conditions across primary care models in Ontario, Canada.

    PubMed

    Laberge, Maude; Wodchis, Walter P; Barnsley, Jan; Laporte, Audrey

    2017-03-22

    The study analyzes the relationship between the risk of a hospitalization for an ambulatory care sensitive condition (ACSC), and the primary care payment and the organizational model used by the patient (fee-for-service, enhanced fee-for-service, blended capitation, blended capitation with interdisciplinary teams). The study used linked patient-level health administrative databases and census data housed at the Institute for Clinical Evaluative Sciences in Ontario. Since the province provides universal health care, the data capture all patients in Ontario, Canada's most populous province, with about 13 million inhabitants. All Ontario patients diagnosed with an ACSC prior to April 1, 2012, who had at least one visit with a physician between April 1, 2012, and March 31, 2013, were included in the study (n = 1,710,310). Each patient was assigned to the primary care model of his/her physician. The different models were categorized as Fee-for-Service (FFS), enhanced-FFS, blended capitation, and interdisciplinary team. A logistic regression was used to model the risk of having an ACSC hospitalization during the one-year observation period. Adjustments were made for patient characteristics (age, sex, health status, and socio-economic status) and for the geographic location of the practice. Using patients belonging to FFS models as the reference group, the risk of an ACSC hospitalization was higher for patients belonging to the blended-capitation model using interdisciplinary teams (Adjusted Odds Ratio [AOR] = 1.06, 95% confidence interval [CI] = 1.00-1.12) and lower for enhanced-FFS (AOR = 0.78, CI = 0.74-0.82) and blended capitation patients (AOR = 0.91, CI = 0.86-0.96). Using patients with hypertension as the reference group, the odds of an ACSC hospitalization were much higher for patients with any other ACSC and increased with patients' morbidity. The risk was lower for patients of higher socio-economic status (AOR = 0.63, CI = 0.60-0.67) in the

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

    PubMed

    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

  5. New approaches to ambulatory care facilities in the United Kingdom--an investor developer's perspective.

    PubMed

    Eminson, C; Dawson, D

    1999-01-01

    The purpose of this article is to describe the strategic context within which ambulatory care facilities are being developed, to consider a range of models of care facilities available, and, by drawing on the experience of the authors, to comment on some of the investment and development issues arising from two projects in progress--the community hospitals in Richmond, Yorkshire, in rural north England, and Thames Ditton on the borders of outer south London. In the final section, we consider the possible future of ambulatory care development in the light of government policy.

  6. The "Sherman effect": decreased ambulatory care volumes in Atlanta during the 1996 Summer Olympic Games.

    PubMed

    Pitts, S R; Kolla, I S

    2000-09-18

    To estimate the effect of the 1996 Atlanta Summer Olympic Games on visits to local ambulatory healthcare facilities. Comparison of median visit rates by time period, obtained from retrospective review of administrative data. The emergency department of the designated athletes' hospital, the public hospital's adult emergency department and adult walk-in clinics, and the adult and paediatric outpatient facilities of a large health maintenance organisation. All 132,826 visitors to the designated facilities during the study interval. Daily visit frequencies at each facility. Our informal observations had suggested that volumes were not as high as expected. In all but the athletes' designated hospital, there was a decrease in average volumes the week before the opening ceremonies, ranging from zero to 8.4% of baseline. Average daily volumes in these non-venue facilities varied from 3.2% above to 16.1% below baseline during the two weeks of the Games, but all experienced an increase in volumes the week after the closing ceremonies, ranging from 3.0% to 13.7% of baseline. Unlike the venue-related facility, community ambulatory care sites did not encounter a significant rise in volumes until after the closing ceremonies. Although confirmation from other events is needed, our data suggest that, in addition to increased preparedness for sudden volume surges, overtime staffing of local facilities during planned mass gatherings should occur not during, but immediately after, the event.

  7. Planning for ambulatory care: simple methods for improving patient flow.

    PubMed

    Schuh, S E; Tolins, I; Westphal, M C; Miller, M C

    1977-06-01

    A combined patient flow and work sampling study was done at the Ambulatory Pediatric Service of the Medical University of South Carolina. The biggest problem was that almost two thirds of the patient's time was spent waiting to see the doctor. Reasons for delay included too few examining rooms, the single block appointment system, and design of the facility.

  8. The impact of office-based care on hospitalizations for ambulatory care sensitive conditions.

    PubMed

    Sundmacher, Leonie; Kopetsch, Thomas

    2015-05-01

    The aim of the study was to quantify the impact of specific medical services in the ambulatory sector (SA) on hospitalizations for ambulatory care sensitive conditions (ACSCs), in order to be able to assess whether and under what conditions specific ambulatory treatments could serve to lower the hospitalization rate. The analysis is based on administrative data showing the complete provision of medical services in the ambulatory sector in Germany and data from other sources. The data were provided by the National Association of Statutory Health Insurance Physicians, the Federal Statistical Agency, the Federal Office of Construction and Regional Planning, and the Federal Insurance Agency. The impact of an increase in specific medical services on hospitalizations for ACSCs was estimated using linear spatial models at the level of the 413 German counties and county boroughs for the years 2007 and 2008. To allow for an undistorted estimation of the coefficients, SA and physician density were instrumented using a two-stage 'least squares' approach. The SA and the rate of hospitalizations for ACSCs were age-standardized. In the models, a well-defined set of covariates was controlled for. According to the models, an additional spent on ACSC treatment decreases the rate of hospitalizations for ACSCs for women and men up to an annual Uniform Value Scale For Doctors' Fees point value of approximately 6,891 and 5,735, respectively. The correlation is not linear but, as suspected, exhibits diminishing marginal returns. Our models suggest that additional medical services reduce the rate of hospitalizations for ACSCs but that this correlation depends on the absolute level of office-based services in a county, all covariates being held equal. Ceteris paribus counties with a very high volume of services exhibit 'flat-of-the-curve medicine', while counties with a very low current level of specific medical services benefit most from an increase in those specific services.

  9. Disparities in potentially avoidable emergency department (ED) care: ED visits for ambulatory care sensitive conditions.

    PubMed

    Johnson, Pamela Jo; Ghildayal, Neha; Ward, Andrew C; Westgard, Bjorn C; Boland, Lori L; Hokanson, Jon S

    2012-12-01

    Hospital care for ambulatory care sensitive conditions (ACSC) is potentially avoidable and often viewed as an indicator of suboptimal primary care. However, potentially preventable encounters with the health care system also occur in emergency department (ED) settings. We examined ED visits to identify subpopulations with disproportionate use of EDs for ACSC care. We analyzed data from the 2007-2009 National Hospital Ambulatory Medical Care Survey for 78,114 ED visits by adults aged 18 and older. Outcomes were ACSC visits determined from the primary ED diagnosis. We constructed analytic groups aligned with Agency for Healthcare Research and Quality's priority populations. Multivariate logistic regression was used to estimate the odds of all-cause, acute, and chronic ACSC visits. We used Stata SE survey techniques to account for the complex survey design. Overall, 8.4% of ED visits were for ACSC, representing over 8 million potentially avoidable ED visits annually. ACSC visits were more likely to result in hospitalization than non-ACSC visits (34.4% vs. 14.0%, P<0.001). Multivariate models revealed significant disparities in ACSC visits to the ED by race/ethnicity, insurance status, age group, and socioeconomic status, although patterns differed for acute and chronic ACSC. Disproportionately higher use of EDs for ACSC care exists for many priority populations and across a broader range of priority populations than previously documented. These differences constitute disparities in potentially avoidable ED visits for ACSC. To avoid exacerbating disparities, health policy efforts to minimize economic inefficiencies in health care delivery by limiting ED visits for ACSC should first address their determinants.

  10. Hospitalizations for ambulatory care-sensitive conditions, Minas Gerais, Southeastern Brazil, 2000 and 2010

    PubMed Central

    Rodrigues-Bastos, Rita Maria; Campos, Estela Márcia Saraiva; Ribeiro, Luiz Cláudio; Bastos, Mauro Gomes; Bustamante-Teixeira, Maria Teresa

    2014-01-01

    OBJECTIVE To analyze hospitalization rates and the proportion of deaths due to ambulatory care-sensitive hospitalizations and to characterize them according to coverage by the Family Health Strategy, a primary health care guidance program. METHODS An ecological study comprising 853 municipalities in the state of Minas Gerais, under the purview of 28 regional health care units, was conducted. We used data from the Hospital Information System of the Brazilian Unified Health System. Ambulatory care-sensitive hospitalizations in 2000 and 2010 were compared. Population data were obtained from the demographic censuses. RESULTS The number of ambulatory care-sensitive hospitalizations declined from 20.75/1,000 inhabitants [standard deviation (SD) = 10.42) in 2000 to 14.92/thousand inhabitants (SD = 10.04) in 2010 Heart failure was the most frequent cause in both years. Hospitalizations rates for hypertension, asthma, and diabetes mellitus, decreased, whereas those for angina pectoris, prenatal and birth disorders, kidney and urinary tract infections, and other acute infections increased. Hospitalization durations and the proportion of deaths due to ambulatory care-sensitive hospitalizations increased significantly. CONCLUSIONS Mean hospitalization rates for sensitive conditions were significantly lower in 2010 than in 2000, but no correlation was found with regard to the expansion of the population coverage of the Family Health Strategy. Hospitalization rates and proportion of deaths were different between the various health care regions in the years evaluated, indicating a need to prioritize the primary health care with high efficiency and quality. PMID:26039399

  11. EHR acceptance factors in ambulatory care: a survey of physician perceptions.

    PubMed

    Morton, Mary E; Wiedenbeck, Susan

    2010-01-01

    With the U.S. government calling for electronic health records (EHRs) for all Americans by the year 2014, adoption of an interoperable EHR is imminent in America's future. However, recent estimates for EHR implementation in the ambulatory care environment are just over 10 percent. This second part of a two-part study examines EHR acceptance factors in an academic-based healthcare system. Innovation diffusion theory and the Technology Acceptance Model provide a combined theoretical framework for this case study. An online questionnaire was administered to 802 faculty, fellow, and resident physicians to explore the factors affecting attitudes toward EHR adoption. In this study, age, years in practice, clinical specialty, health system relationship, and prior computer experience were not predictors of EHR acceptance. In order to facilitate successful adoption of health information systems, social and behavioral factors must be addressed during the EHR planning phase.

  12. EHR Acceptance Factors in Ambulatory Care: A Survey of Physician Perceptions

    PubMed Central

    Morton, Mary E; Wiedenbeck, Susan

    2010-01-01

    With the U.S. government calling for electronic health records (EHRs) for all Americans by the year 2014, adoption of an interoperable EHR is imminent in America's future. However, recent estimates for EHR implementation in the ambulatory care environment are just over 10 percent. This second part of a two-part study examines EHR acceptance factors in an academic-based healthcare system. Innovation diffusion theory and the Technology Acceptance Model provide a combined theoretical framework for this case study. An online questionnaire was administered to 802 faculty, fellow, and resident physicians to explore the factors affecting attitudes toward EHR adoption. In this study, age, years in practice, clinical specialty, health system relationship, and prior computer experience were not predictors of EHR acceptance. In order to facilitate successful adoption of health information systems, social and behavioral factors must be addressed during the EHR planning phase. PMID:20697466

  13. Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care.

    PubMed

    Pfoh, Elizabeth R; Engineer, Lilly; Singh, Hardeep; Hall, Laura Lee; Fried, Ethan D; Berger, Zackary; Wu, Albert W

    2017-02-28

    Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents. This narrative review included articles from PubMed that were: 1) original research; 2) discussed near misses or adverse events in the ambulatory setting; 3) relevant to US health care; and 4) published between 2002 and 2013. After full text review, 38 studies were searched for information on near misses and associated factors. Additionally, we used expert opinion and current inpatient near miss registries to inform registry development. Studies included a variety of safety issues including diagnostic errors, treatment or management-related errors, communication errors, environmental/structural hazards, and health information technology (health IT)-related concerns. The registry, based on the results of the review, updates previous work by including specific sections for errors associated with diagnosis, communication, and environment structure and incorporates specific questions about the role of health information technology. Through use of this registry or future registries that incorporate newly identified categories, near misses in the ambulatory setting can be accurately captured, and that information can be used to improve patient safety.

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

    PubMed

    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 (P<.01). The inconsistent quality of health-related information obtained from the Internet 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.

  15. Psychometric analysis of the ambulatory care learning education environment measure (ACLEEM) in Iran

    PubMed Central

    Naghizadeh Moogari, Zahra; Koohpayehzadeh, Jalil; Roff, Susanne; Montazeri, Ali; Soltani Arabshahi, Seyyed Kamran; Bigdeli, Shoaleh; Moosavi, Maryam; Azaminejad, Faranak; Tavousi, Mahmoud

    2015-01-01

    Background: Examining educational environment (academic and clinical) by means of a valid, reliable and comprehensive questionnaire is a major key in achieving a highly qualified student – oriented curricula. The Persian translation of Ambulatory Care Learning Education Environment Measure-ACLEEM questionnaire has been developed to support this goal, and its psychometrics has been explored in this administration in teaching hospitals affiliated to Tehran University of Medical Sciences. Methods: This descriptive – analytical study involved medical residents in four major clinics. In this study, the ACLEEM Questionnaire was conducted after translating and retranslating the questionnaire and examine the face and content validity, construct validity, test retest reliability and internal consistency coefficient. Results: In this study, 157 out of 192 residents completed the questionnaire (response rate 82%). The mean age of the residents was 31.81 years .The final mean of the questionnaire was calculated as 110.91 out of 200 (with 95% confidence interval). Test – retest stability of the questionnaire was between 0.322 and 0.968. The face validity of the questionnaire was confirmed. The content validity ratio was 0.64; and content validity Index was 0.78. In Exploratory factor analysis, eight factors were confirmatory that changed the orientation of some questions. The Cronbach's alpha coefficient of the whole questionnaire was 0.936. Conclusion: According to the data, the Persian version of the ACLEEM questionnaire has sufficient psychometric reliability and validity to be used for conducting research, teaching and practicing the educational learning environment in ambulatory care in Iran. PMID:26913262

  16. [Patient safety and a culture of responsibility in ambulatory care: strategies for improving practice].

    PubMed

    Lichte, Thomas; Klement, Andreas; Herrmann, Markus

    2009-01-01

    The development of a medical safety culture is spreading beyond the hospital into the ambulatory setting. Patient safety defined as "absence of unwanted events" (primum non nocere) can serve as a starting point for the advancement of our ambulatory medical care system. Error analyses conducted in GP and specialist practices will identify gaps and traps in the system and provide ideas for the development and implementation of new safety strategies in ambulatory patient care. In the light of the structures and processes of GP medical care aspects of patient safety will be correlated to the outcome quality and examples will be discussed. Possible strategies for the improvement of patient safety in GP practice will be presented from the perspective of both patient- and practice individuality.

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

    PubMed

    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.

  18. Developing a nurse-led paracentesis service in an ambulatory care unit.

    PubMed

    Vaughan, Julie

    Ambulatory emergency care units are present in many hospitals and accommodate patients who need urgent medical assessment or procedures but do not require inpatient admission to achieve this. This article reports on a project undertaken in the ambulatory care unit at the Royal United Hospital Bath, which introduced a nurse-led paracentesis service with the intention of reducing waiting times and improving the service for patients. To evaluate the effect of the project, patient satisfaction levels and waiting times were measured before and after the introduction of nurse-led paracentesis. The results confirmed a significant reduction in waiting times after the nurse-led intervention was introduced and high levels of satisfaction. The results provide evidence that nurses are acquiring the knowledge and skills required to undertake interventional procedures that improve the patient's experience while contributing to pioneering developments in ambulatory emergency care services.

  19. Staphylococcus aureus–associated Skin and Soft Tissue Infections in Ambulatory Care

    PubMed Central

    McDonald, L. Clifford; Mandal, Sanjay; Jernigan, Daniel B.

    2006-01-01

    To describe the number and treatment of skin and soft tissue infections likely caused by Staphylococcus aureus in the United States, we analyzed data from the 1992–1994 and 2001–2003 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. Each year, data were reported by an average of 1,400 physicians, 230 outpatient departments, and 390 emergency departments for 30,000, 33,000, and 34,000 visits, respectively. During 2001–2003, the number of annual ambulatory care visits for skin and soft tissue infections was 11.6 million; the visit rate was 410.7 per 10,000 persons. During the study period, rates of overall and physician office visits did not differ; however, rates of visits to outpatient and emergency departments increased by 59% and 31%, respectively. This increase may reflect the emergence of community-acquired methicillin-resistant S. aureus infections. PMID:17283622

  20. Ambulatory blood pressure monitoring in spinal cord injury: clinical practicability.

    PubMed

    Hubli, Michèle; Krassioukov, Andrei V

    2014-05-01

    Trauma to the spinal cord often results not only in sensorimotor but also autonomic impairments. The loss of autonomic control over the cardiovascular system can cause profound blood pressure (BP) derangements in subjects with spinal cord injury (SCI) and may therefore lead to increased cardiovascular disease (CVD) risk in this population. The use of ambulatory blood pressure monitoring (ABPM) allows insights into circadian BP profiles, which have been shown to be of good prognostic value for cardiovascular morbidity and mortality in able-bodied subjects. Past studies in SCI subjects using ABPM have shown that alterations in circadian BP patterns are dependent on the spinal lesion level. Tetraplegic subjects with sensorimotor complete lesions have a decreased daytime arterial BP, loss of the physiological nocturnal BP dip, and higher circadian BP variability, including potentially life-threatening hypertensive episodes known as autonomic dysreflexia (AD), compared with paraplegic and able-bodied subjects. The proposed underlying mechanisms of these adverse BP alterations mainly are attributed to a lost or decreased central drive to sympathetic spinal preganglionic neurons controlling the heart and blood vessels. In addition, several maladaptive anatomical changes within the spinal cord and the periphery, as well as the general decrease of physical daily activity in SCI subjects, account for adverse BP changes. ABPM enables the identification of adverse BP profiles and the associated increased risk for CVD in SCI subjects. Concurrently, it also might provide a useful clinical tool to monitor improvements of AD and lost nocturnal dip after appropriate treatments in the SCI population.

  1. Clinic design, key practice metrics, and resident satisfaction in internal medicine continuity clinics: findings of the educational innovations project ambulatory collaborative.

    PubMed

    Francis, Maureen D; Thomas, Kris; Langan, Michael; Smith, Amy; Drake, Sean; Gwisdalla, Keri Lyn; Jones, Ronald R; Julian, Katherine A; Nabors, Christopher; Pereira, Anne; Rosenblum, Michael; Varney, Andrew; Warm, Eric; Ortiz, Melchor

    2014-06-01

    Internal medicine programs are redesigning ambulatory training to improve the resident experience and answer the challenges of conflicting clinical responsibilities. However, little is known about the effect of clinic redesign on residents' satisfaction. We assessed residents' satisfaction with different resident continuity clinic models in programs participating in the Educational Innovations Project Ambulatory Collaborative (EPAC). A total of 713 internal medicine residents from 12 institutions in the EPAC participated in this cross-sectional study. Each program completed a detailed curriculum questionnaire and tracked practice metrics for participating residents. Residents completed a 3-part satisfaction survey based on the Veterans Affairs Learners' Perception Survey, with additional questions addressing residents' perceptions of the continuous healing relationship and conflicting duties across care settings. THREE CLINIC MODELS WERE IDENTIFIED: traditional weekly experience, combination model with weekly experience plus concentrated ambulatory rotations, and a block model with distinct inpatient and ambulatory blocks. The satisfaction survey showed block models had less conflict between inpatient and outpatient duties than traditional and combination models. Residents' perceptions of the continuous healing relationship was higher in combination models. In secondary analyses, the continuity for physician measure was correlated with residents' perceptions of the continuous healing relationship. Panel size and workload did not have an effect on residents' overall personal experience. Block models successfully minimize conflict across care settings without sacrificing overall resident satisfaction or resident perception of the continuous healing relationship. However, resident perception of the continuous healing relationship was higher in combination models.

  2. Clinic Design, Key Practice Metrics, and Resident Satisfaction in Internal Medicine Continuity Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative

    PubMed Central

    Francis, Maureen D.; Thomas, Kris; Langan, Michael; Smith, Amy; Drake, Sean; Gwisdalla, Keri Lyn; Jones, Ronald R.; Julian, Katherine A.; Nabors, Christopher; Pereira, Anne; Rosenblum, Michael; Varney, Andrew; Warm, Eric; Ortiz, Melchor

    2014-01-01

    Background Internal medicine programs are redesigning ambulatory training to improve the resident experience and answer the challenges of conflicting clinical responsibilities. However, little is known about the effect of clinic redesign on residents' satisfaction. Objective We assessed residents' satisfaction with different resident continuity clinic models in programs participating in the Educational Innovations Project Ambulatory Collaborative (EPAC). Methods A total of 713 internal medicine residents from 12 institutions in the EPAC participated in this cross-sectional study. Each program completed a detailed curriculum questionnaire and tracked practice metrics for participating residents. Residents completed a 3-part satisfaction survey based on the Veterans Affairs Learners' Perception Survey, with additional questions addressing residents' perceptions of the continuous healing relationship and conflicting duties across care settings. Results Three clinic models were identified: traditional weekly experience, combination model with weekly experience plus concentrated ambulatory rotations, and a block model with distinct inpatient and ambulatory blocks. The satisfaction survey showed block models had less conflict between inpatient and outpatient duties than traditional and combination models. Residents' perceptions of the continuous healing relationship was higher in combination models. In secondary analyses, the continuity for physician measure was correlated with residents' perceptions of the continuous healing relationship. Panel size and workload did not have an effect on residents' overall personal experience. Conclusions Block models successfully minimize conflict across care settings without sacrificing overall resident satisfaction or resident perception of the continuous healing relationship. However, resident perception of the continuous healing relationship was higher in combination models. PMID:24949127

  3. The emerging primary care workforce: preliminary observations from the primary care team: learning from effective ambulatory practices project.

    PubMed

    Ladden, Maryjoan D; Bodenheimer, Thomas; Fishman, Nancy W; Flinter, Margaret; Hsu, Clarissa; Parchman, Michael; Wagner, Edward H

    2013-12-01

    Many primary care practices are changing the roles played by the members of their health care teams. The purpose of this article is to describe some of these new roles, using the authors' preliminary observations from 25 site visits to high-performing primary care practices across the United States in 2012-2013. These sites visits, to practices using their workforce creatively, were part of the Robert Wood Johnson Foundation-funded initiative, The Primary Care Team: Learning From Effective Ambulatory Practices.Examples of these new roles that the authors observed on their site visits include medical assistants reviewing patient records before visits to identify care gaps, ordering and administering immunizations using protocols, making outreach calls to patients, leading team huddles, and coaching patients to set self-management goals. The registered nurse role has evolved from an emphasis on triage to a focus on uncomplicated acute care, chronic care management, and hospital-to-home transitions. Behavioral health providers (licensed clinical social workers, psychologists, or licensed counselors) were colocated and integrated within practices and were readily available for immediate consults and brief interventions. Physicians have shifted from lone to shared responsibility for patient panels, with other team members empowered to provide significant portions of chronic and preventive care.An innovative team-based primary care workforce is emerging. Spreading and sustaining these changes will require training both health professionals and nonprofessionals in new ways. Without clinical experiences that model this new team-based care and role models who practice it, trainees will not be prepared to practice as a team.

  4. Design of a Prospective Payment Patient Classification System for Ambulatory Care

    PubMed Central

    Averill, Richard F.; Goldfield, Norbert I.; Wynn, Mark E.; McGuire, Thomas E.; Mullin, Robert L.; Gregg, Laurence W.; Bender, Judith A.

    1993-01-01

    The Ambulatory Patient Groups (APGs) are a patient classification system that was developed to be used as the basis of a prospective payment system (PPS) for the facility cost of outpatient care. This article will review the key characteristics of a patient classification system for ambulatory care, describe the APG development process, and describe a payment model based on the APGs. We present the results of simulating the use of APGs in a prospective payment system, and conclude with a discussion of the implementation issues associated with an outpatient PPS. PMID:10133711

  5. Resource utilisation and cost of ambulatory HIV care in a regional HIV centre in Ireland: a micro-costing study.

    PubMed

    Brennan, Aline; Jackson, Arthur; Horgan, Mary; Bergin, Colm J; Browne, John P

    2015-04-03

    It is anticipated that demands on ambulatory HIV services will increase in coming years as a consequence of the increased life expectancy of HIV patients on highly active anti-retroviral therapy (HAART). Accurate cost data are needed to enable evidence based policy decisions be made about new models of service delivery, new technologies and new medications. A micro-costing study was carried out in an HIV outpatient clinic in a single regional centre in the south of Ireland. The costs of individual appointment types were estimated based on staff grade and time. Hospital resources used by HIV patients who attended the ambulatory care service in 2012 were identified and extracted from existing hospital systems. Associations between patient characteristics and costs per patient month, in 2012 euros, were examined using univariate and multivariate analyses. The average cost of providing ambulatory HIV care was found to be €973 (95% confidence interval €938-€1008) per patient month in 2012. Sensitivity analysis, varying the base-case staff time estimates by 20% and diagnostic testing costs by 60%, estimated the average cost to vary from a low of €927 per patient month to a high of €1019 per patient month. The vast majority of costs were due to the cost of HAART. Women were found to have significantly higher HAART costs per patient month while patients over 50 years of age had significantly lower HAART costs using multivariate analysis. This study provides the estimated cost of ambulatory care in a regional HIV centre in Ireland. These data are valuable for planning services at a local level, and the identification of patient factors, such as age and gender, associated with resource use is of interest both nationally and internationally for the long-term planning of HIV care provision.

  6. Evaluation of The Products of Ambulatory Care and Products of Ambulatory Surgery Classification System For the Military Health Care System.

    DTIC Science & Technology

    1992-09-14

    developed. Utilizing a modified Delphi technique (Polit & Hungler, 1983) the most important administrative and 7 clinical data elements collected in... Techniques , Phys Func 04102 97500 Orthotic Fabrication/Training, Phys Func 04103 97520 Prosthetic Training, Phys Func 04104 97112 Pain Reduction, Phys...Therapy, Manual 06028 97016 Jobet Pump 06029 97110 Tilt Table 06030 90060 Burn Care 06031 97139 Fluidtherapy 06032 90050 Rehabilitation, Cardiac 06033

  7. Hospitalization and ambulatory care in imported-malaria: evaluation of trends and impact on mortality. A prospective multicentric 14-year observational study.

    PubMed

    Casalino, Enrique; Etienne, Aurélie; Mentré, France; Houzé, Sandrine

    2016-06-07

    Hospitalization is usually recommended for imported malaria. The goal of the present study is to evaluate the evolution in clinical pathways while measuring their impact on mortality. This is a 14-year prospective observational study divided into three periods. We evaluated for adult (≥15 years) and paediatric (<15 years) case trends in severity, clinical pathways (hospitalization in medical ward (MW) or intensive care unit (ICU), ambulatory care) and mortality. In total, 21,386 imported malaria cases were included, 4269 of them were paediatrics (20 %). Rises in severe forms for adults [from 8 % in period 1-14 % in period 3 (p = 0.0001)] and paediatrics [from 12 to 18 % (p < 0.0001)] were found. For adults, MW admission rates decreased [-15 % (CI 95 % -17; -13)] while ambulatory care [+7 % (CI 95 % 5-9)] and ICU admission rates [+4 % (CI 95 % 3-5)] increased. For paediatrics, increase in ICU admissions (+3 %) was shown. We did not observe any change in overall mortality during the study periods, whether among adults or children, regardless of care pathway. The present study indicates a changing management of imported malaria in adults, with an increasing trend for ambulatory care. The absence of change in mortality for adults indicates that ambulatory care can be proposed for adults presenting non-severe imported malaria.

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

    PubMed

    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.

  9. Rural Ambulatory Access for Semi-Urgent Care and the Relationship of Distance to an Emergency Department.

    PubMed

    Parks, Ashley; Hoegh, Andy; Kuehl, Damon

    2015-07-01

    Availability of timely access to ambulatory care for semi-urgent medical concerns in rural and suburban locales is unknown. Further distance to an emergency department (ED) may require rural clinics to serve as surrogate EDs in their region, and make it more likely for these clinics to offer timely appointments. We determined the availability of urgent (within 48 hours) access to ambulatory care for non-established visiting patients, and assessed the effect of insurance and ability to pay cash on a patient's success in scheduling an appointment in rural and suburban Eastern United States. We also assessed how proximity to EDs and urgent care (UC) facilities influenced access to semi-urgent ambulatory appointments at primary care facilities. The Appalachian Trail, which runs from Georgia to Maine, was used as a transect to select 190 rural and suburban primary care clinics located along its entire length. We calculated their location and distance to the nearest hospital-based ED or UC via Google Earth. A sham patient representing a non-established visiting patient called each clinic over a four-month period (2013), requesting an appointment in the next 48 hours for one of three scripted clinical vignettes representing common semi-urgent ambulatory concerns. We randomized the scenarios and insurance statuses (insured vs. uninsured). Each clinic was contacted twice, once with the caller representing an insured patient, once with the caller representing an uninsured patient. When the caller was representing an uninsured patient, any required upfront payment was requested from each clinic. One hundred dollars was used as a cutoff between the uninsured as a distinction between those able to afford substantial upfront sums and those who could not. To determine if proximity to other sources of care impacted a clinic's ability to grant an appointment, distance to the nearest ED or UC was modeled as a dichotomous variable using 30 miles as the divider. Of 380 requests, 96

  10. Physician incentives to improve quality and the delivery of high quality ambulatory medical care

    PubMed Central

    Bishop, Tara F.; Federman, Alex D.; Ross, Joseph S.

    2012-01-01

    Objective To determine the prevalence of physician incentives for quality and to test the hypothesis that quality of ambulatory medical care is better by physicians with these incentives. Study Design Cross-sectional study using data from the National Ambulatory Medical Care Survey Method We examined the association between physician compensation based on quality, physician compensation based on satisfaction, and public reporting of practice measures and twelve measures of high quality ambulatory care. Results Overall, 20.8% of visits were to physicians whose compensation was partially based on quality, 17.7% of visits were to physicians whose compensation was partially based on patient satisfaction, and 10.0% of visits were to physicians who publicly reported performance measures. Quality of ambulatory care varied: weight reduction counseling occurred in 12.0% of preventative care visits by obese patients whereas urinalysis was not performed in 93.0% of preventative care visits. In multivariable analyses, there were no statistically significant associations between compensation for quality and delivery of any of the 12 measures, nor between compensation for satisfaction and 11 of the 12 measures; the exception was BMI screening in preventative visits (47.8% vs. 56.2%, adjusted p=0.004). There was also no statistically significant association between public reporting and delivery of 11 of 12 measures; the exception was weight reduction counseling for overweight patients (10.0% vs. 25.5%, adjusted p=0.01). Conclusions We found no consistent association between incentives for quality and 12 measures of high quality ambulatory care. PMID:22554038

  11. Ambulatory Blood Pressure Monitoring in Spinal Cord Injury: Clinical Practicability

    PubMed Central

    Hubli, Michèle

    2014-01-01

    Abstract Trauma to the spinal cord often results not only in sensorimotor but also autonomic impairments. The loss of autonomic control over the cardiovascular system can cause profound blood pressure (BP) derangements in subjects with spinal cord injury (SCI) and may therefore lead to increased cardiovascular disease (CVD) risk in this population. The use of ambulatory blood pressure monitoring (ABPM) allows insights into circadian BP profiles, which have been shown to be of good prognostic value for cardiovascular morbidity and mortality in able-bodied subjects. Past studies in SCI subjects using ABPM have shown that alterations in circadian BP patterns are dependent on the spinal lesion level. Tetraplegic subjects with sensorimotor complete lesions have a decreased daytime arterial BP, loss of the physiological nocturnal BP dip, and higher circadian BP variability, including potentially life-threatening hypertensive episodes known as autonomic dysreflexia (AD), compared with paraplegic and able-bodied subjects. The proposed underlying mechanisms of these adverse BP alterations mainly are attributed to a lost or decreased central drive to sympathetic spinal preganglionic neurons controlling the heart and blood vessels. In addition, several maladaptive anatomical changes within the spinal cord and the periphery, as well as the general decrease of physical daily activity in SCI subjects, account for adverse BP changes. ABPM enables the identification of adverse BP profiles and the associated increased risk for CVD in SCI subjects. Concurrently, it also might provide a useful clinical tool to monitor improvements of AD and lost nocturnal dip after appropriate treatments in the SCI population. PMID:24175653

  12. Using ambulatory care sensitive hospitalisations to analyse the effectiveness of primary care services in Mexico.

    PubMed

    Lugo-Palacios, David G; Cairns, John

    2015-11-01

    Ambulatory care sensitive hospitalisations (ACSH) have been widely used to study the quality and effectiveness of primary care. Using data from 248 general hospitals in Mexico during 2001-2011 we identify 926,769 ACSHs in 188 health jurisdictions before and during the health insurance expansion that took place in this period, and estimate a fixed effects model to explain the association of the jurisdiction ACSH rate with patient and community factors. National ACSH rate increased by 50%, but trends and magnitude varied at the jurisdiction and state level. We find strong associations of the ACSH rate with socioeconomic conditions, health care supply and health insurance coverage even after controlling for potential endogeneity in the rolling out of the insurance programme. We argue that the traditional focus on the increase/decrease of the ACSH rate might not be a valid indicator to assess the effectiveness of primary care in a health insurance expansion setting, but that the ACSH rate is useful when compared between and within states once the variation in insurance coverage is taken into account as it allows the identification of differences in the provision of primary care. The high heterogeneity found in the ACSH rates suggests important state and jurisdiction differences in the quality and effectiveness of primary care in Mexico. Copyright © 2015 Elsevier Ltd. All rights reserved.

  13. The Use of Ambulatory Blood Pressure Monitoring As Standard of Care in Pediatrics

    PubMed Central

    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

  14. The Use of Ambulatory Blood Pressure Monitoring As Standard of Care in Pediatrics.

    PubMed

    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.

  15. Rural Ambulatory Access for Semi-Urgent Care and the Relationship of Distance to an Emergency Department

    PubMed Central

    Parks, Ashley; Hoegh, Andy; Kuehl, Damon

    2015-01-01

    Introduction Availability of timely access to ambulatory care for semi-urgent medical concerns in rural and suburban locales is unknown. Further distance to an emergency department (ED) may require rural clinics to serve as surrogate EDs in their region, and make it more likely for these clinics to offer timely appointments. We determined the availability of urgent (within 48 hours) access to ambulatory care for non-established visiting patients, and assessed the effect of insurance and ability to pay cash on a patient’s success in scheduling an appointment in rural and suburban Eastern United States. We also assessed how proximity to EDs and urgent care (UC) facilities influenced access to semi-urgent ambulatory appointments at primary care facilities. Methods The Appalachian Trail, which runs from Georgia to Maine, was used as a transect to select 190 rural and suburban primary care clinics located along its entire length. We calculated their location and distance to the nearest hospital-based ED or UC via Google Earth. A sham patient representing a non-established visiting patient called each clinic over a four-month period (2013), requesting an appointment in the next 48 hours for one of three scripted clinical vignettes representing common semi-urgent ambulatory concerns. We randomized the scenarios and insurance statuses (insured vs. uninsured). Each clinic was contacted twice, once with the caller representing an insured patient, once with the caller representing an uninsured patient. When the caller was representing an uninsured patient, any required upfront payment was requested from each clinic. One hundred dollars was used as a cutoff between the uninsured as a distinction between those able to afford substantial upfront sums and those who could not. To determine if proximity to other sources of care impacted a clinic’s ability to grant an appointment, distance to the nearest ED or UC was modeled as a dichotomous variable using 30 miles as the

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

    ERIC Educational Resources Information Center

    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…

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

    ERIC Educational Resources Information Center

    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…

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

    PubMed Central

    Robinson, Hal; Engelhardt, Thomas

    2017-01-01

    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. PMID:28458577

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

    PubMed

    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.

  20. Career ladder program for registered nurses in ambulatory care.

    PubMed

    Nelson, Joan; Sassaman, Becky; Phillips, Alison

    2008-01-01

    RN ladder programs are designed to inspire and reward clinical excellence. Kaiser Permanente Colorado's (KPCO) career ladder program emerged as a result of a labor-management partnership. Career ladder point assignments are reflective of the organization's priorities and values. KPCO's career ladder point tool awards RNs for formal and continuing education, professional presentations, organizational experience and experience as an RN, certifications and active professional memberships, leadership activities, research and publications, and nursing-related volunteer work. Participation in the RN career ladder requires that the nurse achieve a self-determined, manager-approved, measurable goal that will improve patient care. Career ladder nurses at KPCO were significantly more involved in leadership and interdisciplinary activities, quality improvement projects, and preceptorship.

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

    PubMed Central

    Yang, Ling-Yu; Lynn, An-Min; Chen, Tzeng-Ji

    2015-01-01

    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. PMID:26540064

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

    PubMed

    Yang, Ling-Yu; Lynn, An-Min; Chen, Tzeng-Ji

    2015-11-02

    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.

  3. Role of Pediatricians in the Ambulatory Care of Children in Taiwan, 1999-2011.

    PubMed

    Chuang, Chieh-Mao; Chan, I-Ching; Lee, Yu-Sheng; Tsao, Pei-Chen; Yang, Chia-Feng; Soong, Wen-Jue; Chen, Tzeng-Ji; Jeng, Mei-Jy

    2015-08-01

    Pediatricians are physicians trained to provide comprehensive nonsurgical health care for children, but parents may consult other specialists when seeking medical help for their children. This study was designed to analyze the role of pediatricians and the changes in the patterns of ambulatory visits among different specialties for children under the age of 18 years in Taiwan during the past 13 years. Data on ambulatory visits of children aged 0-17 years from 1999 to 2011 were retrieved from the National Health Insurance Research Database. The physician's specialty, level of the hospital, year of visit, age of the patient, and diagnoses of each ambulatory visit were analyzed. Four of the most commonly visited specialties-pediatrics, otolaryngology, family medicine, and internal medicine-were compared. The yearly trend of ambulatory visits to different specialties, difference in various age groups, influence of hospital levels, and the top 10 diagnoses were analyzed. A total of 1,618,033 ambulatory visits were identified and enrolled into our study. A comparison of the proportions of ambulatory visits between 1999-2003 and 2007-2011 showed that the proportions of visits increased from 27.1 ± 1.3% to 35.4 ± 1.0% for pediatricians, decreased from 32.8 ± 1.8% to 17.0 ± 0.8% for family physicians, and did not change for otolaryngologists and internal medicine physicians. Specifically, pediatricians were visited more often if the children were younger, or if the health-care facility (level of hospital) was either a medical center or a regional hospital. Upper respiratory tract infection was the top diagnosis, followed by acute bronchitis, and acute and chronic tonsillitis. The role of pediatricians in children's ambulatory care increased in importance from 1999 to 2011 in Taiwan. However, approximately two thirds of children sought ambulatory medical help from nonpediatric physicians. Thus, it is important to educate and encourage parents to visit

  4. Ambulatory and home blood pressure monitoring: gaps between clinical guidelines and clinical practice in Singapore

    PubMed Central

    Setia, Sajita; Subramaniam, Kannan; Teo, Boon Wee; Tay, Jam Chin

    2017-01-01

    Purpose Out-of-office blood pressure (BP) measurements (home blood pressure monitoring [HBPM] and ambulatory blood pressure monitoring [ABPM]) provide important additional information for effective hypertension detection and management decisions. Therefore, out-of-office BP measurement is now recommended by several international guidelines. This study evaluated the practice and uptake of HBPM and ABPM among physicians from Singapore. Materials and methods A sample of physicians from Singapore was surveyed between 8 September and 5 October 2016. Those included were in public or private practice had been practicing for ≥3 years, directly cared for patients ≥70% of the time, and treated ≥30 patients for hypertension per month. The questionnaire covered six main categories: general BP management, BP variability (BPV) awareness/diagnosis, HBPM, ABPM, BPV management, and associated training needs. Results Sixty physicians (30 general practitioners, 20 cardiologists, and 10 nephrologists) were included (77% male, 85% aged 31–60 years, and mean 22-year practice). Physicians recommended HBPM and ABPM to 81% and 27% of hypertensive patients, respectively. HBPM was most often used to monitor antihypertensive therapy (88% of physicians) and 97% thought that ABPM was useful for providing information on BPV. HBPM instructions often differed from current guideline recommendations in terms of frequency, number of measurements, and timing. The proportion of consultation time devoted to discussing HBPM and BPV was one-quarter or less for 73% of physicians, and only 55% said that they had the ability to provide education on HBPM and BPV. Patient inertia, poor patient compliance, lack of medical consultation time, and poor patient access to a BP machine were the most common challenges for implementing out-of-office BP monitoring. Conclusion Although physicians from Singapore do recommend out-of-office BP measurement to patients with hypertension, this survey identified several

  5. Ambulatory and home blood pressure monitoring: gaps between clinical guidelines and clinical practice in Singapore.

    PubMed

    Setia, Sajita; Subramaniam, Kannan; Teo, Boon Wee; Tay, Jam Chin

    2017-01-01

    Out-of-office blood pressure (BP) measurements (home blood pressure monitoring [HBPM] and ambulatory blood pressure monitoring [ABPM]) provide important additional information for effective hypertension detection and management decisions. Therefore, out-of-office BP measurement is now recommended by several international guidelines. This study evaluated the practice and uptake of HBPM and ABPM among physicians from Singapore. A sample of physicians from Singapore was surveyed between 8 September and 5 October 2016. Those included were in public or private practice had been practicing for ≥3 years, directly cared for patients ≥70% of the time, and treated ≥30 patients for hypertension per month. The questionnaire covered six main categories: general BP management, BP variability (BPV) awareness/diagnosis, HBPM, ABPM, BPV management, and associated training needs. Sixty physicians (30 general practitioners, 20 cardiologists, and 10 nephrologists) were included (77% male, 85% aged 31-60 years, and mean 22-year practice). Physicians recommended HBPM and ABPM to 81% and 27% of hypertensive patients, respectively. HBPM was most often used to monitor antihypertensive therapy (88% of physicians) and 97% thought that ABPM was useful for providing information on BPV. HBPM instructions often differed from current guideline recommendations in terms of frequency, number of measurements, and timing. The proportion of consultation time devoted to discussing HBPM and BPV was one-quarter or less for 73% of physicians, and only 55% said that they had the ability to provide education on HBPM and BPV. Patient inertia, poor patient compliance, lack of medical consultation time, and poor patient access to a BP machine were the most common challenges for implementing out-of-office BP monitoring. Although physicians from Singapore do recommend out-of-office BP measurement to patients with hypertension, this survey identified several important gaps in knowledge and clinical practice.

  6. Big data and ambulatory care: breaking down legal barriers to support effective use.

    PubMed

    Thorpe, Jane Hyatt; Gray, Elizabeth Alexandra

    2015-01-01

    Big data is heralded as having the potential to revolutionize health care by making large amounts of data available to support care delivery, population health, and patient engagement. Critics argue that big data's transformative potential is inhibited by privacy requirements that restrict health information exchange. However, there are a variety of permissible activities involving use and disclosure of patient information that support care delivery and management. This article presents an overview of the legal framework governing health information, dispels misconceptions about privacy regulations, and highlights how ambulatory care providers in particular can maximize the utility of big data to improve care.

  7. Essentials of Ambulatory Care a postgraduate-level, interdisciplinary, interprofessional curriculum at the University of Minnesota. .

    PubMed

    Buum, Heather Thompson; Mustapha, Taj; Borman-Shoap, Emily; Adam, Patricia; Dierich, Mary; Hager, Keri

    2015-04-01

    Team-based care is a cornerstone of primary care. However, in medical school and residency, trainees get little formal education on this as a concept and how it works in an outpatient setting. Faculty members from the University of Minnesota created a one-day workshop, "Essentials of Ambulatory Care," to help residents in primary care specialties as well as pharmacy and nursing students pursuing advanced degrees better understand the roles and responsibilities of members of the primary care team. The workshop also helped them develop new skills for doing patient-centered visits. This article describes the workshop and what we learned from those who participated in the first session.

  8. Have Racial Disparities In Ambulatory Care Sensitive Admissions Abated Over Time?

    PubMed Central

    Mukamel, Dana B.; Ladd, Heather; Li, Yue; Temkin-Greener, Helena; Ngo-Metzger, Quyen

    2015-01-01

    Background Racial disparities in access to care and access to high quality care have been persistent over many decades. They have been documented in all areas of health care, including ambulatory care. Policy initiatives have been implemented to address disparities and close the gaps in care that minorities face. Less is known about the effectiveness of these polices. Objectives To evaluate whether disparities in quality of ambulatory care have abated during the 2000 decade by answering two questions: 1) Were there differences in ambulatory care sensitive hospital admissions rates by race? 2) Have these differences been declining over time? Research design Multivariable linear regressions with fixed county effects and robust standard errors of longitudinal panel data. Subjects 4,032,322 discharges in 172 counties in 6 states during 2003–2009. Measures Prevention Quality Indicators (PQIs) developed by the Agency for Healthcare Research and Quality, by county and race calculated from the HCUP data set. Results In 2003 the overall PQI admission rates were higher for African-Americans (around 16.5/1000) than for Whites (around 15/1000). By 2009, the overall and the chronic PQI admission rates declined significantly (p< 0.01) for Whites. They either did not decline or increased for African-Americans. Acute PQI rates declined significantly for Whites and remained stable for African-Americans. Conclusions Policies addressing persisting racial disparities in quality of ambulatory care for African-Americans should focus on the chronic PQIs. Additionally, efforts should be made to improve data quality for race and ethnicity information on hospital discharge data to enable informed policy evaluation and planning. PMID:26421373

  9. Daily Energy Expenditure and Its Relation to Health Care Costs in Patients Undergoing Ambulatory Electrocardiographic Monitoring.

    PubMed

    George, Jason; Abdulla, Rami Khoury; Yeow, Raymond; Aggarwal, Anshul; Boura, Judith; Wegner, James; Franklin, Barry A

    2017-02-15

    Our increasingly sedentary lifestyle is associated with a heightened risk of obesity, diabetes, heart disease, and cardiovascular mortality. Using the recently developed heart rate index formula in 843 patients (mean ± SD age 62.3 ± 15.7 years) who underwent 24-hour ambulatory electrocardiographic (ECG) monitoring, we estimated average and peak daily energy expenditure, expressed as metabolic equivalents (METs), and related these data to subsequent hospital encounters and health care costs. In this cohort, estimated daily average and peak METs were 1.7 ± 0.7 and 5.5 ± 2.1, respectively. Patients who achieved daily bouts of peak energy expenditure ≥5 METs had fewer hospital encounters (p = 0.006) and median health care costs that were nearly 50% lower (p <0.001) than their counterparts who attained <5 METs. In patients whose body mass index was ≥30 kg/m(2), there were significant differences in health care costs depending on whether they achieved <5 or ≥5 METs estimated by ambulatory ECG monitoring (p = 0.005). Interestingly, patients who achieved ≥5 METs had lower and no significant difference in their health care costs, regardless of their body mass index (p = 0.46). Patients with previous percutaneous coronary intervention who achieved ≥5 METs had lower health care costs (p = 0.044) and fewer hospital encounters (p = 0.004) than those who achieved <5 METs. In conclusion, average and peak daily energy expenditures estimated from ambulatory ECG monitoring may provide useful information regarding health care utilization in patients with and without previous percutaneous coronary intervention, irrespective of body habitus. Our findings are the first to link lower intensities of peak daily energy expenditure, estimated from ambulatory ECG monitoring, with increased health care utilization.

  10. A Study of the Ambulatory Care Quality Assurance Program at DeWitt Army Community Hospital, Fort Belvoir, Virginia

    DTIC Science & Technology

    1982-12-01

    Practice Inpatient Services. These will include medical , pediatric , obstetrical and gynecologic patient categories. Audits will be conducted once monthly...CHAPTER I INTRODUCTION Development of the Problem "The impetus for the study of the ambulatory care Quality Assurance Program at the US Army Medical ...regarding the quality of ambulatory care. Repeatedly, the outcome of quality assurance( QA) related committee meetings, e.g., the Medical Care

  11. AmbCare--A Relational Database for Implementing a Community Pharmacy Ambulatory Care Teaching Program: A Descriptive Report.

    ERIC Educational Resources Information Center

    Magarian, Edward O.; Peterson, Charles D.

    1995-01-01

    An IBM-compatible information storage and retrieval software program was developed to support an eight-week community pharmacy ambulatory care clerkship for entry-level Doctor of Pharmacy students. The program helps evaluate and identify patients for health and medication problems, perform patient risk-factor assessment, monitor drug therapy,…

  12. Use of ambulatory physician group clinical information by hospital-based users within an integrated delivery network.

    PubMed

    Bowes, Watson A

    2007-10-11

    At Intermountain Healthcare, as part of a broad information system transition plan, a proposal was made to replace the integrated ambulatory EHR, used by 550 physicians, with a new stand alone EHR. The notion leading to the proposal was that ambulatory data was infrequently accessed outside of the ambulatory setting. To test this notion, retrospective analysis was done to determine the number of ambulatory patient events accessed by hospital based users. 399 Departments from the Hospital-based group accessed 1, 984, 785 patient events that originated from within the ambulatory group in a 90 day period. This study showed that a significant number of ambulatory patient records were viewed by a wide range of hospital-based users. The decision to replace the legacy ambulatory system with a new, stand alone system was postponed. This analysis was critical in planning the road map for a new integrated clinical information system.

  13. Evaluation of Ambulatory Care Classification Systems for the Military Health Care System

    DTIC Science & Technology

    1990-12-01

    reports will be directed to the following: U.S. Department of Commerce C) eu urNational Tecnical Information Services (NTIS) (peD ntu5285 Port RoyalRoad p s...of those examined for possible evaluation. Subzequent phases will focus on PACs with an ambulatory surgery component included called Products of...Ambulatory Surgery (PAS), Ambulatory Patient Groups (APGs) which are based on AVGs, Emergency Department Groups (EDGs) (Cameron, Baraff, and Sekhon, 1990

  14. Effect of Intensive Versus Standard Clinic-Based Hypertension Management on Ambulatory Blood Pressure: Results From the SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory Blood Pressure Study.

    PubMed

    Drawz, Paul E; Pajewski, Nicholas M; Bates, Jeffrey T; Bello, Natalie A; Cushman, William C; Dwyer, Jamie P; Fine, Lawrence J; Goff, David C; Haley, William E; Krousel-Wood, Marie; McWilliams, Andrew; Rifkin, Dena E; Slinin, Yelena; Taylor, Addison; Townsend, Raymond; Wall, Barry; Wright, Jackson T; Rahman, Mahboob

    2017-01-01

    The effect of clinic-based intensive hypertension treatment on ambulatory blood pressure (BP) is unknown. The goal of the SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory BP ancillary study was to evaluate the effect of intensive versus standard clinic-based BP targets on ambulatory BP. Ambulatory BP was obtained within 3 weeks of the 27-month study visit in 897 SPRINT participants. Intensive treatment resulted in lower clinic systolic BP (mean difference between groups=16.0 mm Hg; 95% confidence interval, 14.1-17.8 mm Hg), nighttime systolic BP (mean difference=9.6 mm Hg; 95% confidence interval, 7.7-11.5 mm Hg), daytime systolic BP (mean difference=12.3 mm Hg; 95% confidence interval, 10.6-13.9 mm Hg), and 24-hour systolic BP (mean difference=11.2 mm Hg; 95% confidence interval, 9.7-12.8 mm Hg). The night/day systolic BP ratio was similar between the intensive (0.92±0.09) and standard-treatment groups (0.91±0.09). There was considerable lack of agreement within participants between clinic systolic BP and daytime ambulatory systolic BP with wide limits of agreement on Bland-Altman plots. In conclusion, targeting a systolic BP of <120 mm Hg, when compared with <140 mm Hg, resulted in lower nighttime, daytime, and 24-hour systolic BP, but did not change the night/day systolic BP ratio. Ambulatory BP monitoring may be required to assess the effect of targeted hypertension therapy on out of office BP. Further studies are needed to assess whether targeting hypertension therapy based on ambulatory BP improves clinical outcomes.

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

    PubMed Central

    Chen, Tsung-Fu; Liang, Jyh-Chong; Lin, Tzu-Bin; Tsai, Chin-Chung

    2016-01-01

    Background 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. Objective 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. Methods 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. Results 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 (P<.01). Conclusions The inconsistent quality of health-related information obtained from the Internet 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. PMID:27927606

  16. Diagnoses Treated in Ambulatory Care Among Homeless-Experienced Veterans: Does Supported Housing Matter?

    PubMed Central

    Gabrielian, Sonya; Yuan, Anita H.; Andersen, Ronald M.; Gelberg, Lillian

    2016-01-01

    Purpose Little is known about how permanent supported housing influences ambulatory care received by homeless persons. To fill this gap, we compared diagnoses treated in VA Greater Los Angeles (VAGLA) ambulatory care between Veterans who are formerly homeless—now housed/case managed through VA Supported Housing (“VASH Veterans”)—and currently homeless. Methods We performed secondary database analyses of homeless-experienced Veterans (n = 3631) with VAGLA ambulatory care use from October 1, 2010 to September 30, 2011. We compared diagnoses treated—adjusting for demographics and need characteristics in regression analyses—between VASH Veterans (n = 1904) and currently homeless Veterans (n = 1727). Results On average, considering 26 studied diagnoses, VASH (vs currently homeless) Veterans received care for more (P < .05) diagnoses (mean = 2.9/1.7). Adjusting for demographics and need characteristics, VASH Veterans were more likely (P < .05) than currently homeless Veterans to receive treatment for diagnoses across categories: chronic physical illness, acute physical illness, mental illness, and substance use disorders. Specifically, VASH Veterans had 2.5, 1.7, 2.1, and 1.8 times greater odds of receiving treatment for at least 2 condition in these categories, respectively. Among participants treated for chronic illnesses, adjusting for predisposing and need characteristics, VASH (vs currently homeless) Veterans were 9%, 8%, and 11% more likely to have 2 or more visits for chronic physical illnesses, mental illnesses, and substance use disorder, respectively. Conclusion Among homeless-experienced Veterans, permanent supported housing may reduce disparities in the treatment of diagnoses commonly seen in ambulatory care. PMID:27343544

  17. Hospitalizations owing to ambulatory care sensitive conditions in Florianopolis, Santa Catarina - an ecological study, 2001-2011.

    PubMed

    Brasil, Vinicius Paim; Costa, Juvenal Soares Dias da

    2016-01-01

    to evaluate trends in rates of hospitalizations owing to ambulatory care sensitive conditions in the municipality of Florianópolis, Santa Catarina, Brazil, from 2001 to 2011, and to assess correlation with the public health expendutures Family Health Strategy (FHS) population coverage. this was an ecological study using Ministry of Health secondary data; data were analyzed using Poisson Regression. the regression coefficient was 0.97, showing a decrease of 3% per year in hospitalizations owing to ambulatory care sensitive conditions, a three-fold increase in FHS coverage and seven times more financial investment per capita in health services, from R$67.65 in 2001 to R$471.03 in 2011; FHS investments per capita in health and population coverage were negatively correlated to the rate of hospitalizations owing to ambulatory care sensitive conditions. financial investment and FHS expansion had led to major reductions in the rate of hospitalizations owing to ambulatory care sensitive conditions.

  18. A Chronic Disease State Simulation in an Ambulatory Care Elective Course

    PubMed Central

    Roberson, Cindy Leslie A.; Prasad-Reddy, Lalita

    2015-01-01

    Objective. To implement a chronic disease state simulation in an ambulatory care elective course and to assess the simulation’s impact on students’ perceptions of their empathy toward patients and of their counseling skills. Design. The chronic disease state simulation occurred over 2 weeks. Students alternated playing the role of patient and pharmacist. As patients, students adhered to medication regimens, lifestyle modifications, and blood glucose or blood pressure monitoring. As pharmacists, students conducted patient interviews, and provided education and counseling. Empathy and counseling skills were assessed through course surveys, written reflections, and SOAP notes. Assessment. Results from a cohort of 130 students indicated the simulation enhanced students’ perceptions of their abilities to empathize with and counsel patients with chronic diseases. Conclusion. The chronic disease state simulation provides a novel approach to develop skills needed for working with complex patient cases in ambulatory care settings. PMID:26839423

  19. Information needs of cancer patients receiving chemotherapy in an ambulatory-care setting.

    PubMed

    Lock, Karen K; Willson, Barbara

    2002-12-01

    The purpose of this study was to assess the information needs of cancer patients receiving chemotherapy and to explore their preferred styles of receiving education in an ambulatory-care setting. Patient information needs and preferences were measured using a 17-item questionnaire. This descriptive study included a sample of 101 cancer patients undergoing outpatient chemotherapy. The most commonly expressed information needs concerned: side effects of treatment, drug information, and coping strategies. Some patients expressed a preference for information in their primary language. The results support the use of online learning in this setting. Patients identified one-on-one discussion with nurses and doctors as the preferred way to receive information. In order to meet the individual needs of cancer patients, education should be provided in a variety of learning modalities. The results of this study should help to guide patient education initiatives in oncology ambulatory care.

  20. The predictive value of selected job rewards on occupational therapists' job satisfaction in ambulatory care settings.

    PubMed

    Painter, J; Akroyd, D; Wilson, S; Figuers, C

    1995-01-01

    Using a perceived reward model of overall job satisfaction, this study utilized a correlational research design with multiple regression analysis to determine the predictive power of extrinsic rewards and intrinsic rewards, collectively and individually, as determinants of overall job satisfaction among registered occupational therapists (OTR) working full-time in ambulatory care settings. The intrinsic rewards (task involvement and task autonomy), collectively and individually, were perceived to be significant overall job satisfaction determinants. General working conditions was the only significant extrinsic reward. Given the demand for OTRs in ambulatory care settings, a better understanding of factors that influence overall job satisfaction among OTRs could prove beneficial in developing appropriate recruitment and retention job design strategies.

  1. Effective change management in a regional Sub-acute Ambulatory Care Services setting.

    PubMed

    Campbell, Bruce W

    2012-02-01

    Government policies and community expectations in Australia continually lead to calls for healthcare change. These changes are often met with resistance from clinicians and managers. Making change happen requires consideration of the way policies, culture, context, shared vision and leadership can drive or impede change. This reflective case study critically investigates one change process; the evolution of a Sub-acute Ambulatory Care Services (SACS) program in an Australian regional hospital over a 3-year period. The new Community Rehabilitation Services (CRS) program evolved from a merger of Centre and Home Based Rehabilitation (CBR and HBR). Hospital amalgamations, closures and privatisation, and the Department of Health policy relating to SACS, ambulatory care and rehabilitation were some of the key elements explored in this paper.

  2. Ascertainment of Outpatient Visits by Patients with Diabetes: The National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS)

    PubMed Central

    Asao, Keiko; McEwen, Laura N.; Lee, Joyce M.; Herman, William H.

    2015-01-01

    Aims To estimate and evaluate the sensitivity and specificity of providers’ diagnosis codes and medication lists to identify outpatient visits by patients with diabetes. Methods We used data from the 2006 to 2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. We assessed the sensitivity and specificity of providers’ diagnoses and medication lists to identify patients with diabetes, using the checkbox for diabetes as the gold standard. We then examined differences in sensitivity by patients’ characteristics using multivariate logistic regression models. Results The checkbox identified 12,647 outpatient visits by adults with diabetes among the 70,352 visits used for this analysis. The sensitivity and specificity of providers’ diagnoses or listed diabetes medications were 72.3% (95% CI: 70.8% to 73.8%) and 99.2% (99.1% to 99.4%), respectively. Diabetic patients ≥75 years pf age, women, non-Hispanics, and those with private insurance or Medicare were more likely to be missed by providers’ diagnoses and medication lists. Diabetic patients who had more diagnosis codes and medications recorded, had glucose or hemoglobin A1c measured, or made office- rather than hospital-outpatient visits were less likely to be missed. Conclusions Providers’ diagnosis codes and medication lists fail to identify approximately one quarter of outpatient visits by patients with diabetes. PMID:25891975

  3. Effects of preventive home visits on health care costs for ambulatory frail elders: a randomized controlled trial.

    PubMed

    Kono, Ayumi; Kanaya, Yukiko; Tsumura, Chieko; Rubenstein, Laurence Z

    2013-10-01

    Reducing health care costs through preventive geriatric care has become a high priority in Japan. We analyzed data from a randomized controlled trial to examine the effects of a preventive home visit program on health care costs among ambulatory frail elders. Structured preventive home visits by nurses or care managers were provided to the visit group every 6 months over 2 years. The enrolled participants (N = 323) were randomly assigned to either the visit group (N = 161) or the control group (N = 162). We analyzed the health care costs, including the costs for hospitalizations and outpatient clinic utilization for participants who had health care insurance from the local government (N = 307). The visit group included 154 individuals in the visit group and 153 people in the control group. Total health care costs over the study period were not significantly different between groups, but at most monthly time points costs and those for outpatient clinic utilization in the visit group were lower than those in the control group. Hospitalizations, which accounted for more than ¥ 500,000 JPY per month, were less likely to occur more often among participants in the visit group (N = 71) than in the control group (N = 113) (OR = 0.63; p = 0.002). These results suggest that a preventive home visit program may reduce monthly health care costs, primarily by reducing hospitalization costs.

  4. Leveraging Electronic Health Record Implementation to Facilitate Clinical and Operational Quality Improvement in an Ambulatory Surgical Clinic.

    PubMed

    Bobadilla, Joseph L; Roe, Cathy S; Estes, Patricia; Lackey, Jennifer; Steltenkamp, Carol L

    The implementation of electronic health records is a challenging, complex process requiring significant resources. The temptation is to convert a paper process into electronic format. This strategy fosters a familiar product to the users but is fraught with pitfalls. We chose to utilize the opportunity of the implementation of an enterprise-wide ambulatory electronic health record to foster an overreaching clinical and operational improvement project in a multispecialty surgical ambulatory clinic practice. We interrogated every aspect of the practice: clinic design, scheduling, physical space, staffing, and clinical and operational workflows. We present here the results of a 3-year process improvement.

  5. Manager's leadership is the main skill for ambulatory health care plan success.

    PubMed

    Marin, Gustavo Horacio; Silberman, Martin; Colombo, Maria Virginia; Ozaeta, Belen; Henen, Jaime

    2015-01-01

    To demonstrate effectiveness of ambulatory health care plan implementation among institutions and variables associated with the differences observed. Randomized selection of primary health care (PHC) centers was done. Leadership ability of the plan manager was explored. Univariate/bivariate analyses were performed to observe correlation between variables. Two groups of PHC centers were established according to the efficacy of plan implementation: high and low performance. Differences between groups were observed (592%-1023% more efficacy in controls and practices; P < .001). Leadership was responsible for the main differences observed. Leadership of manager for implementation of the health care plan was the major important variable to reach the best efficacy standards.

  6. Improving identification of fall-related injuries in ambulatory care using statistical text mining.

    PubMed

    Luther, Stephen L; McCart, James A; Berndt, Donald J; Hahm, Bridget; Finch, Dezon; Jarman, Jay; Foulis, Philip R; Lapcevic, William A; Campbell, Robert R; Shorr, Ronald I; Valencia, Keryl Motta; Powell-Cope, Gail

    2015-06-01

    We determined whether statistical text mining (STM) can identify fall-related injuries in electronic health record (EHR) documents and the impact on STM models of training on documents from a single or multiple facilities. We obtained fiscal year 2007 records for Veterans Health Administration (VHA) ambulatory care clinics in the southeastern United States and Puerto Rico, resulting in a total of 26 010 documents for 1652 veterans treated for fall-related injury and 1341 matched controls. We used the results of an STM model to predict fall-related injuries at the visit and patient levels and compared them with a reference standard based on chart review. STM models based on training data from a single facility resulted in accuracy of 87.5% and 87.1%, F-measure of 87.0% and 90.9%, sensitivity of 92.1% and 94.1%, and specificity of 83.6% and 77.8% at the visit and patient levels, respectively. Results from training data from multiple facilities were almost identical. STM has the potential to improve identification of fall-related injuries in the VHA, providing a model for wider application in the evolving national EHR system.

  7. Improving Identification of Fall-Related Injuries in Ambulatory Care Using Statistical Text Mining

    PubMed Central

    McCart, James A.; Berndt, Donald J.; Hahm, Bridget; Finch, Dezon; Jarman, Jay; Foulis, Philip R.; Lapcevic, William A.; Campbell, Robert R.; Shorr, Ronald I.; Valencia, Keryl Motta; Powell-Cope, Gail

    2015-01-01

    Objectives. We determined whether statistical text mining (STM) can identify fall-related injuries in electronic health record (EHR) documents and the impact on STM models of training on documents from a single or multiple facilities. Methods. We obtained fiscal year 2007 records for Veterans Health Administration (VHA) ambulatory care clinics in the southeastern United States and Puerto Rico, resulting in a total of 26 010 documents for 1652 veterans treated for fall-related injury and 1341 matched controls. We used the results of an STM model to predict fall-related injuries at the visit and patient levels and compared them with a reference standard based on chart review. Results. STM models based on training data from a single facility resulted in accuracy of 87.5% and 87.1%, F-measure of 87.0% and 90.9%, sensitivity of 92.1% and 94.1%, and specificity of 83.6% and 77.8% at the visit and patient levels, respectively. Results from training data from multiple facilities were almost identical. Conclusions. STM has the potential to improve identification of fall-related injuries in the VHA, providing a model for wider application in the evolving national EHR system. PMID:25880936

  8. Effectiveness of involving pharmacists in the process of ambulatory health care to improve drug treatment adherence and disease control.

    PubMed

    Mino-León, Dolores; Reyes-Morales, Hortensia; Flores-Hernández, Sergio

    2015-02-01

    To evaluate the effectiveness of incorporating the pharmacist into the ambulatory health care team to increase the proportion of patients with type 2 diabetes mellitus (T2DM) and/or hypertension who adhere to their drug regimen and to improve disease control. A non-randomized clinical trial was carried out in patients with T2DM and/or hypertension from two primary care clinics. Patients from one of the clinics comprised the intervention group (IG) who received 'counselling' from the pharmacist. The control group (CG) was comprised of patients who attended another clinic and received the usual care. Adherence was measured by counting pills; hypertension control was evaluated by blood pressure and diabetes control by blood glucose. Statistical analysis was carried out by intention to treat using generalized linear models. There were 440 patients included. There was no difference in the proportion of IG and CG patients who adhered to treatment according to baseline measurements. An increase in the proportion of adherence at baseline and final determination was observed in both groups (IG 71-80%, P=0.006 and CG 72-87%, P=0.000). Generalized linear models showed a 55% or higher probability of IG patients achieving control of hypertension in comparison with the CG. Patients from the IG with T2DM have 13% more possibility of achieving glycaemic control than those of the CG. Counselling offered by the pharmacist proved to be effective for improving drug adherence of diabetic and hypertensive patients in ambulatory health care. © 2014 John Wiley & Sons, Ltd.

  9. Experts Foresee a Major Shift From Inpatient to Ambulatory Care.

    PubMed

    Beans, Bruce E

    2016-04-01

    An American Society of Health-System Pharmacists Research and Education Foundation report predicts trends in health care delivery and financing, drug development and therapeutics, pharmaceutical marketplace, pharmacy workforce, and more.

  10. Determinants of Patient Satisfaction in Internal Medicine Resident Continuity Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative

    PubMed Central

    Francis, Maureen D.; Warm, Eric; Julian, Katherine A.; Rosenblum, Michael; Thomas, Kris; Drake, Sean; Gwisdalla, Keri Lyn; Langan, Michael; Nabors, Christopher; Pereira, Anne; Smith, Amy; Sweet, David; Varney, Andrew; Francis, Mark L.

    2014-01-01

    Background Many internal medicine programs have reorganized their resident continuity clinics to improve the ambulatory care experience for residents. The effect of this redesign on patient satisfaction is largely unknown. Methods Our multi-institutional, cross-sectional study included 569 internal medicine residents from 11 programs participating in the Educational Innovations Project Ambulatory Collaborative. An 11-item patient satisfaction survey from the Consumer Assessment of Healthcare Providers and Systems was used to assess patient satisfaction, comparing patient satisfaction in traditional models of weekly continuity clinic with 2 new clinic models. We then examined the relationship between patient satisfaction and other practice variables. Results Patient satisfaction responses related to resident listening and communication skills, knowledge of medical history, perception of adequate visit time, overall rating, and willingness to refer to family and friends were significantly better in the traditional and block continuity models than the combination model. Higher ambulatory workload was associated with reduced patient perception of respect shown by the physician. The percentage of diabetic patients with glycated hemoglobin < 8% was positively correlated with number of visits, knowledge of medical history, perception of respect, and higher scores for recommending the physician to others. The percentage of diabetic patients with low density lipoprotein < 100 mg/dL was positively correlated with the physician showing respect. Conclusions Patient satisfaction was similar in programs using block design and traditional models for continuity clinic, and both outperformed the combination model programs. There was a delicate balance between workload and patient perception of the physician showing respect. Care outcome measures for diabetic patients were associated with aspects of patient satisfaction. PMID:26279771

  11. Determinants of Patient Satisfaction in Internal Medicine Resident Continuity Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative.

    PubMed

    Francis, Maureen D; Warm, Eric; Julian, Katherine A; Rosenblum, Michael; Thomas, Kris; Drake, Sean; Gwisdalla, Keri Lyn; Langan, Michael; Nabors, Christopher; Pereira, Anne; Smith, Amy; Sweet, David; Varney, Andrew; Francis, Mark L

    2014-09-01

    Many internal medicine programs have reorganized their resident continuity clinics to improve the ambulatory care experience for residents. The effect of this redesign on patient satisfaction is largely unknown. Our multi-institutional, cross-sectional study included 569 internal medicine residents from 11 programs participating in the Educational Innovations Project Ambulatory Collaborative. An 11-item patient satisfaction survey from the Consumer Assessment of Healthcare Providers and Systems was used to assess patient satisfaction, comparing patient satisfaction in traditional models of weekly continuity clinic with 2 new clinic models. We then examined the relationship between patient satisfaction and other practice variables. Patient satisfaction responses related to resident listening and communication skills, knowledge of medical history, perception of adequate visit time, overall rating, and willingness to refer to family and friends were significantly better in the traditional and block continuity models than the combination model. Higher ambulatory workload was associated with reduced patient perception of respect shown by the physician. The percentage of diabetic patients with glycated hemoglobin < 8% was positively correlated with number of visits, knowledge of medical history, perception of respect, and higher scores for recommending the physician to others. The percentage of diabetic patients with low density lipoprotein < 100 mg/dL was positively correlated with the physician showing respect. Patient satisfaction was similar in programs using block design and traditional models for continuity clinic, and both outperformed the combination model programs. There was a delicate balance between workload and patient perception of the physician showing respect. Care outcome measures for diabetic patients were associated with aspects of patient satisfaction.

  12. Patterns of Ambulatory Medical Care Utilization and Rheumatologist Consultation Predating the Diagnosis of Systemic Lupus Erythematosus: A National Population-Based Study

    PubMed Central

    Koo, Malcolm; Huang, Kuang-Yung; Tung, Chien-Hsueh; Lu, Ming-Chi

    2014-01-01

    Objective To investigate the records of ambulatory medical care from patients predating the diagnosis of systemic lupus erythematosus (SLE) using nationwide, population-based claims data. Methods The frequencies and costs of ambulatory medical care utilization in 337 newly-diagnosed SLE cases between 2004 and 2010, identified from Taiwan's National Health Insurance Research Database, were compared with 1,348 controls who were frequency matched for sex, age, and the catastrophic illness certificate application year of the cases. Results Patients with SLE had a median frequency of ambulatory medical care utilization compared with controls one year prior to the index date (22 vs. 2, P<0.001). The differences were significant throughout all eight annual periods. Similarly, the inflation-adjusted costs of ambulatory medical care utilization in patients with SLE increased annually over the study period, from a median of US$18 eight years prior to the index date to US$680 one year prior to the index date. Diseases of the respiratory system (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 460–519), digestive system (ICD-9-CM codes 520–579), musculoskeletal system and connective tissue (ICD-9-CM codes 710–739, excluding 710.0), and skin and subcutaneous tissue (ICD-9-CM codes 680–709) were the top four common causes of visits in the 0.5 to 2 year period preceding the index date and percentages of SLE patients suffered from these disorders increased progressively over the study period. Only 56.4% of the patients with SLE had consulted a rheumatologist and most of the serology tests were done within one year predating the index date. Conclusions Increased frequencies and costs of ambulatory care utilization among Taiwanese patients with SLE occurred several years predating their definitive SLE diagnosis. When multisystemic disorders are presented in young female patients, the possibility of SLE should be considered and

  13. Strategic response by providers to specialty hospitals, ambulatory surgery centers, and retail clinics.

    PubMed

    Burns, Lawton R; David, Guy; Helmchen, Lorens A

    2011-04-01

    Radical innovation and disruptive technologies are frequently heralded as a solution to delivering higher quality, lower cost health care. According to the literature on disruption, local hospitals and physicians (incumbent providers) may be unable to competitively respond to such "creative destruction" and alter their business models for a host of reasons, thus threatening their future survival. However, strategic management theory and research suggest that, under certain conditions, incumbent providers may be able to weather the discontinuities posed by the disrupters. This article analyzes 3 disruptive innovations in service delivery: single-specialty hospitals, ambulatory surgical centers, and retail clinics. We first discuss the features of these innovations to assess how disruptive they are. We then draw on the literature on strategic adaptation to suggest how incumbents develop competitive responses to these disruptive innovations that assure their continued survival. These arguments are then evaluated in a field study of several urban markets based on interviews with both incumbents and entrants. The interviews indicate that entrants have failed to disrupt incumbent providers primarily as a result of strategies pursued by the incumbents. The findings cast doubt on the prospects for these disruptive innovations to transform health care.

  14. [Reimbursement and importance of hyperbaric oxygenation for diabetic foot ulcers in German publically funded ambulatory health care].

    PubMed

    Gawlik, C; Schmacke, N; Gibis, B; Sander, G; Rheinberger, P

    2001-11-01

    The Standing Committee of Statutory Health Insurance Physicians and Sickness Funds is the legal body that makes decisions on reimbursement for health care services in the German ambulatory health care sector. In 1994, the Committee declined the reimbursement of hyperbaric oxygen therapy (HBO). In 1999, a new deliberation of the efficacy, appropriateness and cost-effectiveness of HBO was initiated as the proponents of this technology claimed that the efficacy of HBO had since been proven in clinical trials. The deliberation was announced and published in the journal of the German Medical Association (Deutsches Arzteblatt) and the federal register (Bundesanzeiger). All institutions, groups, and interested individuals were given the opportunity to provide a written statement. The statements and, in particular, the scientific literature cited in those statements, were critically appraised by the Committee. In addition, the Committee conducted a thorough review of the literature, guidelines and status of the therapy in other health care systems. More than 40 potential indications for the use of HBO were reviewed by the committee. One indication was for diabetic foot ulcers. Most clinical trials related to this field represented only retrospective case series, which, in view of the established therapies, cannot be used as a sound basis for the acceptance of HBO as a new technology for the therapy of diabetic foot ulcers. Some studies were planned as randomized controlled trials but had serious methodological flaws in conduct and analysis. The main problems were the low numbers of patients included and serious inbalances of important and well known prognostic factors between the treatment groups. Systematic reviews that were published in the international literature after the decision of the Committee drew similar conclusions in view of the methodological flaws in the clinical trial data. In summary, the Committee decided once again to decline coverage of HBO in German

  15. Ambulatory care for cancer in the United States: results from two national surveys comparing visits to physicians' offices and hospital outpatient departments.

    PubMed Central

    Richardson, Lisa C.; Tangka, Florence K.

    2007-01-01

    BACKGROUND: Among the general population, type of health insurance has been reported to affect the location of ambulatory visits and the content of those visits. We examined where cancer patient visits occurred (physicians' offices or hospital clinics), and whether anticancer therapy is administered or prescribed. METHODS: Cross-sectional study using National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey (NAMCS/NHAMCS) data to characterize ambulatory cancer patient visits from 2001-2003. Multivariable logistic regression analyses were performed to identify factors associated with where a cancer patient went for care (office practice versus hospital clinic) and anticancer therapy received. RESULTS: Thirteen percent of patients visited hospital clinics, with the remainder visiting office-based settings. Younger cancer patients and those with Medicaid were more likely to visit hospital clinics compared to older and privately insured cancer patients. Cancer patients with <6 visits in the last year were less likely to be seen in the office setting. Patients with lung cancer, lymphoma/leukemia and melanoma were less likely to have anticancer therapy administered or prescribed compared to breast cancer patients. The uninsured were less likely to have anticancer administered or prescribed compared with the privately insured. CONCLUSIONS: Cancer patients with Medicaid were more likely to visit hospital clinics than privately insured patients. Treatment was associated with cancer type, not where care occurred and health insurance type, though there was a trend for the uninsured and those insured by Medicaid to be less likely to be administered or be prescribed anticancer therapy. PMID:18229771

  16. Ambulatory Subspecialty Visits in a Large Pediatric Primary Care Network

    PubMed Central

    Vernacchio, Louis; Muto, Jennifer M; Young, Gregory; Risko, Wanessa

    2012-01-01

    Objective To determine patterns of subspecialty utilization within a pediatric primary care network. Data Sources/Study Setting Paid claims from a large not-for-profit health plan for patients of The Pediatric Physicians' Organization at Children's, a network of private pediatric practices affiliated with Children's Hospital Boston. Principal Findings The subspecialty visit rate was 1.01 visits per subject-year. In 2007, 56.8 percent of subjects had no subspecialty visits, whereas 4.2 percent had ≥5 visits; the corresponding figures in 2008 were 54.1 and 4.5 percent, respectively. The most frequently visited subspecialties were Ophthalmology, Orthopedics, Dermatology, Otorhinolaryngology, and Allergy/Immunology. Visit rates varied sevenfold by practice. Conclusions Wide practice variability in pediatric subspecialty utilization suggests an opportunity for reducing unnecessary visits. Better integration between primary care and the most commonly used subspecialties will be needed to meaningfully reduce unnecessary visits and enhance value. PMID:22375886

  17. [Nursing care in ambulatory surgery at a teaching hospital: patients, procedures and biological and psychosocial needs].

    PubMed

    Pinto, Tatiane Vegette; Araújo, Izilda Esmênia Muglia; Gallani, Maria Cecília Bueno Jayme

    2005-01-01

    This descriptive study aimed to characterize the profile of 167 subjects who were treated at the Ambulatory Surgical Center of a University Hospital in São Paulo State and procedures realized at the Ambulatory Surgical Center, as well as to identify the biological and psychosocial needs of these patients. Data were obtained through a semistructured interview and patients' files and were subject to descriptive analysis. The group was characterized by an equal number of individuals from both genders; average age was 51 years and socioeconomic levels were poor. The most common surgical and anesthetic procedures were ophthalmologic procedures and use of local anesthesia with or without sedation. The biological needs were: altered arterial pressure, electrocardiographic alterations, use of medication, allergy to medication, prolonged fasting, nausea, vomiting and pain. The psychosocial needs were: worry, fear, anxiety, discomfort caused by waiting for the realization of procedures and doubts or lack of information concerning perioperative care.

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

    PubMed

    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.

  19. Teaching final-year medical students in a paediatric ambulatory care unit.

    PubMed

    Behmanesh, Fatemeh; Ahanchian, Hamid; Vakili, Rahim; Ahanchian, Narges; Bagheri, Sepideh

    2014-08-01

    The importance of community-based ambulatory experiences for medical students has been emphasised in the past few decades. Although such teaching programmes are assumed to be better for medical students, there is little evidence comparing the out-patient and in-patient experiences in student education. We carried out a study to compare the educational experiences between two in-patient and out-patient clinical units. Over a 12-week paediatric clerkship, 38 senior medical students attending the paediatric ward were divided into two groups. One group attended a 15-day paediatric out-patient clinic while the other group attended the in-patient programme. Those who took part in the out-patient clinic programme obtained better scores in a test on common paediatric ambulatory problems when compared with the students who exclusively attended the in-patient teaching programme. The former group all agreed that this ambulatory paediatric course was a beneficial learning experience and consistent with their future career needs. © 2014 John Wiley & Sons Ltd.

  20. Ambulatory Hemodynamic Monitoring Reduces Heart Failure Hospitalizations in "Real-World" Clinical Practice.

    PubMed

    Desai, Akshay S; Bhimaraj, Arvind; Bharmi, Rupinder; Jermyn, Rita; Bhatt, Kunjan; Shavelle, David; Redfield, Margaret M; Hull, Robert; Pelzel, Jamie; Davis, Kevin; Dalal, Nirav; Adamson, Philip B; Heywood, J Thomas

    2017-05-16

    In the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in New York Heart Association [NYHA] Functional Class III Heart Failure Patients) trial, heart failure hospitalization (HFH) rates were lower in patients managed with guidance from an implantable pulmonary artery pressure sensor compared with usual care. This study examined the effectiveness of ambulatory hemodynamic monitoring in reducing HFH outside of the clinical trial setting. We conducted a retrospective cohort study using U.S. Medicare claims data from patients undergoing pulmonary artery pressure sensor implantation between June 1, 2014, and December 31, 2015. Rates of HFH during pre-defined periods before and after implantation were compared using the Andersen-Gill extension to the Cox proportional hazards model while accounting for the competing risk of death, ventricular assist device implantation, or cardiac transplantation. Comprehensive heart failure (HF)-related costs were compared over the same periods. Among 1,114 patients receiving implants, there were 1,020 HFHs in the 6 months before, compared with 381 HFHs, 139 deaths, and 17 ventricular assist device implantations and/or transplants in the 6 months after implantation (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.49 to 0.61; p < 0.001). This lower rate of HFH was associated with a 6-month comprehensive HF cost reduction of $7,433 per patient (IQR: $7,000 to $7,884), and was robust in analyses restricted to 6-month survivors. Similar reductions in HFH and costs were noted in the subset of 480 patients with complete data available for 12 months before and after implantation (HR: 0.66; 95% CI: 0.57 to 0.76; p < 0.001). As in clinical trials, use of ambulatory hemodynamic monitoring in clinical practice is associated with lower HFH and comprehensive HF costs. These benefits are sustained to 1 year and support the "real-world" effectiveness of this approach to HF management. Copyright

  1. Avoidable hospitalizations for ambulatory care sensitive conditions as an indicator of primary health care effectiveness in Argentina.

    PubMed

    Rubinstein, Adolfo; López, Analía; Caporale, Joaquín; Valanzasca, Pilar; Irazola, Vilma; Rubinstein, Fernando

    2014-01-01

    Avoidable hospitalizations for ambulatory care sensitive conditions (AH-ACSCs) identify health problems that could be avoided by improving primary health care (PHC). On the basis of hospital discharges from Argentine public sector facilities, an expert panel convened to define a list of AH-ACSCs for children and adults. AH-ACSCs represented less than 30% of hospitalizations. Compared with country averages, poorer districts showed large differences in trends for adults but not for children. Despite that AH-ACSCs have demonstrated empirical validity to evaluate health system performance, its implementation to assess PHC in countries like Argentina, with pluralistic and fragmented health care systems, remains a big challenge.

  2. Hospitalisation Rates for Ambulatory Care Sensitive Conditions for Persons with and without an Intellectual Disability--A Population Perspective

    ERIC Educational Resources Information Center

    Balogh, R.; Brownell, M.; Ouellette-Kuntz, H.; Colantonio, A.

    2010-01-01

    Background: There is evidence that persons with an intellectual disability (ID) face barriers to primary care; however, this has not been extensively studied at the population level. Rates of hospitalisation for ambulatory care sensitive conditions are used as an indicator of access to, and quality of, primary care. The objective of the study was…

  3. Hospitalisation Rates for Ambulatory Care Sensitive Conditions for Persons with and without an Intellectual Disability--A Population Perspective

    ERIC Educational Resources Information Center

    Balogh, R.; Brownell, M.; Ouellette-Kuntz, H.; Colantonio, A.

    2010-01-01

    Background: There is evidence that persons with an intellectual disability (ID) face barriers to primary care; however, this has not been extensively studied at the population level. Rates of hospitalisation for ambulatory care sensitive conditions are used as an indicator of access to, and quality of, primary care. The objective of the study was…

  4. Precepting humanism: strategies for fostering the human dimensions of care in ambulatory settings.

    PubMed

    Gracey, Catherine F; Haidet, Paul; Branch, William T; Weissmann, Peter; Kern, David E; Mitchell, Gary; Frankel, Richard; Inui, Thomas

    2005-01-01

    Humanistic medical care is an important element of quality health care, and teaching humanism is increasingly recognized as an integral component of medical education. The goal of this article is to illustrate a series of tools that are effective in fostering both the provision and teaching of humanistic medical care in the ambulatory setting. Through a series of discussions, workshops, literature review, and practice, the authors have identified critical elements that promote the teaching of humanistic care. These elements include establishing a humanistic learning climate, creating clear individualized learning goals within a framework of humanism, developing an educational diagnosis of the learner, integrating psychosocial issues into the teaching intervention, reflecting on the learning experience with the learner, providing feedback throughout the teaching encounter, and planning follow-up with the learner. Strategies for implementation of these critical elements are presented with an emphasis on efficient educational interactions as required by busy ambulatory settings. Through the effective use of these teaching strategies, one can promote the teaching of the human dimensions of care in the outpatient setting.

  5. Oncology nurses' perceptions of their relations with family members in an ambulatory cancer care setting: a mixed methods study.

    PubMed

    Lobchuk, Michelle; Udod, Sonia

    2011-01-01

    Trends signal an increasing prevalence of people living through and beyond a cancer diagnosis with an enhanced reliance on ambulatory cancer care services and family caregiving. Despite this trend, there has been limited focus on nurses' experiences with providing support to families who care for patients in the community. For oncology nurses in ambulatory care settings, job satisfaction has decreased significantly as they are concerned with their ability to consistently provide safe and quality care to patients and their family. Although other studies indicated that the lack of time and limited resources are regrettably accepted aspects of nurses' work environments, our mixed methods small-scale study addressed how work environments still can meet the growing need for enhanced support and relations among nurses, patients, and families in ambulatory cancer care.

  6. [Contract Conditions for GPs in Training while Working in Ambulatory Care].

    PubMed

    Herrmann, W J; Thiel, P; Weinert, K

    2016-06-01

    In Germany, the situation of GPs in training has received growing attention. Central funding of GPs in training who are working in ambulatory care has been increased up to 3 500 Euros/month. However, the contract conditions of GPs in training who are working in ambulatory care have been unknown as yet. An online survey was undertaken. We recruited GPs in training by snowball sampling making use of national and local organisations of GPs and GPs in training. Our questionnaire consisted of questions concerning sociodemographic variables, gross wage, working hours, holidays and free days for educational purposes. Data were analysed by descriptive statistical methods. 152 participants fulfilled the inclusion criteria. 127 were full time GPs in training. The median of gross wage was 3 500 Euros/month, the mean gross wage was 3 878 Euros/month. The gross wage per hour was lower than that for GPs in training who are working in hospitals. Especially part time GPs in training had a lower gross wage per hour. One third of the GPs in training had no free days for educational purposes. More than half of the GPs in training had a weekly meeting with their supervisor, however, more than one third of GPs in training had no or only irregular meetings with their supervisor. In Germany, GPs in training earn in ambulatory care less than in hospital care. They do not have sufficient free days for educational purposes and often there is a lack of supervision. This seems to indicate that GPs in training are mainly considered as cheap coworkers instead of trainees. © Georg Thieme Verlag KG Stuttgart · New York.

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

    PubMed

    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

  8. BRIEF REPORT: Multiprogram Evaluation of Reading Habits of Primary Care Internal Medicine Residents on Ambulatory Rotations

    PubMed Central

    Lai, Cindy J; Aagaard, Eva; Brandenburg, Suzanne; Nadkarni, Mohan; Wei, Henry G; Baron, Robert

    2006-01-01

    OBJECTIVE To assess the reading habits and educational resources of primary care internal medicine residents for their ambulatory medicine education. DESIGN Cross-sectional, multiprogram survey of primary care internal medicine residents. PARTICIPANTS/SETTING Second- and third-year residents on ambulatory care rotations at 9 primary care medicine programs (124 eligible residents; 71% response rate). MEASUREMENTS AND MAIN RESULTS Participants were asked open-ended and 5-point Likert-scaled questions about reading habits: time spent reading, preferred resources, and motivating and inhibiting factors. Participants reported reading medical topics for a mean of 4.3 ± 3.0 SD hours weekly. Online-only sources were the most frequently utilized medical resource (mean Likert response 4.16 ± 0.87). Respondents most commonly cited specific patients' cases (4.38 ± 0.65) and preparation for talks (4.08 ± 0.89) as motivating factors, and family responsibilities (3.99 ± 0.65) and lack of motivation (3.93 ± 0.81) as inhibiting factors. CONCLUSIONS To stimulate residents' reading, residency programs should encourage patient- and case-based learning; require teaching assignments; and provide easy access to online curricula. PMID:16704393

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

    PubMed

    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.

  10. Medication Safety: an audit of medication discrepancies in transferring type 2 diabetes mellitus (T2DM) patients from Australian primary care to tertiary ambulatory care.

    PubMed

    Azzi, Madonna; Constantino, Maria; Pont, Lisa; Mcgill, Margaret; Twigg, Stephen; Krass, Ines

    2014-08-01

    To identify, classify and determine the factors associated with medication discrepancies for type 2 diabetes mellitus (T2DM) patients, referred from primary care to a tertiary ambulatory clinic. Retrospective audit of outpatient clinic records. Royal Prince Alfred Hospital (RPAH) Diabetes Ambulatory Care Centre. 300 randomly selected adult T2DM patients who attended the Diabetes Centre between 01 January 2010 and 31 December 2011. The rates and types of medication discrepancies were identified by comparing the structured nurse-patient interview (SNPI) with the primary care [General Practitioner (GP)] referral letter, where the SNPI was considered the best possible medication history. Discrepancies were identified as addition, omission, dose and insulin-type discrepancies. Each category was mutually exclusive. Over 80% of referral letters contained at least one discrepancy with a median of two discrepancies per referral. Of a total of 744 discrepancies, the majority were omissions (58.9%). Insulins had the highest discrepancy rate. Factors independently associated with medication discrepancies were GP referral letter type, total number of medications and medication regimen type. A high rate of medication discrepancies was found in GP referral letters for patients referred to this clinic. Automated GP referral letters and inaccurate GP records may have contributed to this, highlighting the need for routine medication reconciliation at transitions of care, to ensure prescribers have access to correct medication information to inform decision-making and ensure optimal patient outcomes. © The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

  11. [Case finding in early prevention networks - a heuristic for ambulatory care settings].

    PubMed

    Barth, Michael; Belzer, Florian

    2016-06-01

    One goal of early prevention is the support of families with small children up to three years who are exposed to psychosocial risks. The identification of these cases is often complex and not well-directed, especially in the ambulatory care setting. Development of a model of a feasible and empirical based strategy for case finding in ambulatory care. Based on the risk factors of postpartal depression, lack of maternal responsiveness, parental stress with regulation disorders and poverty a lexicographic and non-compensatory heuristic model with simple decision rules, will be constructed and empirically tested. Therefore the original data set from an evaluation of the pediatric documentary form on psychosocial issues of families with small children in well-child visits will be used and reanalyzed. The first diagnostic step in the non-compensatory and hierarchical classification process is the assessment of postpartal depression followed by maternal responsiveness, parental stress and poverty. The classification model identifies 89.0 % cases from the original study. Compared to the original study the decision process becomes clearer and more concise. The evidence-based and data-driven model exemplifies a strategy for the assessment of psychosocial risk factors in ambulatory care settings. It is based on four evidence-based risk factors and offers a quick and reliable classification. A further advantage of this model is that after a risk factor is identified the diagnostic procedure will be stopped and the counselling process can commence. For further validation of the model studies, in well suited early prevention networks are needed.

  12. Determinants of physicians' technology acceptance for e-health in ambulatory care.

    PubMed

    Dünnebeil, Sebastian; Sunyaev, Ali; Blohm, Ivo; Leimeister, Jan Marco; Krcmar, Helmut

    2012-11-01

    Germany is introducing a nation-wide telemedicine infrastructure that enables electronic health services. The project is facing massive resistance from German physicians, which has led to a delay of more than five years. Little is known about the actual burdens and drivers for adoption of e-health innovations by physicians. Based on a quantitative study of German physicians who participated in the national testbed for telemedicine, this article extends existing technology acceptance models (TAM) for electronic health (e-health) in ambulatory care settings and elaborates on determinants of importance to physicians in their decision to use e-health applications. This study explores the opinions, attitudes, and knowledge of physicians in ambulatory care to find drivers for technology acceptance in terms of information technology (IT) utilization, process and security orientation, standardization, communication, documentation and general working patterns. We identified variables within the TAM constructs used in e-health research that have the strongest evidence to determine the intention to use e-health applications. The partial least squares (PLS) regression model from data of 117 physicians showed that the perceived importance of standardization and the perceived importance of the current IT utilization (p<0.01) were the most significant drivers for accepting electronic health services (EHS) in their practice. Significant influence (p<0.05) was shown for the perceived importance of information security and process orientation as well as the documentation intensity and the e-health-related knowledge. This study extends work gleaned from technology acceptance studies in healthcare by investigating factors which influence perceived usefulness and perceived ease of use of e-health services. Based on these empirical findings, we derive implications for the design and introduction of e-health services including suggestions for introducing the topic to physicians in

  13. [Establishing an Ambulatory Health-Care Centre (AHCC) at a University Hospital].

    PubMed

    Krüll, A; Debatin, J F

    2013-02-01

    Since January 2004 hospitals have the opportunity to establish an ambulatory health-care centre (Medizinisches Versorgungszentrum - MVZ) as a result of the introduction of the Health-care Modernisation Act (Gesetz zur Modernisierung der gesetzlichen Krankenversicherung - GMG). After about a half-year preparatory phase, the UKE, in September 2004, began operation of the "Ambulanzzentrum des UKE GmbH" (a limited liability company) as the first MVZ at a university hospital in Germany. We report here on the establishment of the MVZ and the experience made. In the initial phase, only the medical fields of radiation therapy and nuclear medicine were represented. Both disciplines, especially radiation therapy, were existentially threatened by the extensive loss of ambulatory patients. The central motive for the establishment of the ambulatory health-care centre was to secure the survival of both disciplines and to preserve existing jobs. After it was put into operation, the referrals from practice-based colleagues to both radiation therapy and nuclear medicine increased quickly. The positive developments caused other departments of the UKE to express their interest in supplementing their outpatient activities with facilities in the MVZ. Over the following years, the ambulance centre grew steadily. Now 24 departments are represented in the MVZ, and the centre has a total of 49 positions for physicians contracted by and registered within the German public health insurance system. The number of salaried doctors has risen to 85, although many of these only work part time in the MVZ. Also more than 83 non-medical staff members were hired over the years. These were mostly physiotherapists, radiographers, and medical assistants. With the growing number of departments in the MVZ, the number of treated cases grew steadily. Currently approximately 20 000 cases are treated in each quarter of a year. The experience made while establishing an ambulatory health-care centre is very

  14. A Work Sampling Assessment of the Nursing Delivery of Palliative Care in Ambulatory Cancer Centers.

    PubMed

    Davison, Jennifer; Schenker, Yael; Donovan, Heidi; Rosenzweig, Margaret

    2016-08-01

    Most cancer care occurs within infusion rooms at ambulatory cancer centers, which are staffed by RNs administering chemotherapies and other cancer care medications. Many patients receiving these therapies have basic palliative care needs that could be addressed by the RNs. However, the extent to which these RNs spend their time on basic, or "primary," palliative care is unknown. The aim of this project was to conduct a work sampling assessment of infusion room RNs' work activities and provision of primary palliative care. A single observer conducted direct observation work sampling at three academic cancer center infusion rooms. Nursing tasks were recorded via freehand text and later assigned an appropriate task code. Observed infusion room RNs spent about 1% of their time on direct care palliative care tasks, primarily symptom assessment. The remainder of their time was divided among direct (28%) and indirect (56%) nonpalliative care activities, unit-related activities (7%), and personal time (9%). Infusion room RNs spent less than a third of their time on administering direct patient care and very minimal time on performing palliative care activities.

  15. Integrating TeamSTEPPS(®) into ambulatory reproductive health care: Early successes and lessons learned.

    PubMed

    Paul, Maureen E; Dodge, Laura E; Intondi, Evelyn; Ozcelik, Guzey; Plitt, Ken; Hacker, Michele R

    2017-04-01

    Most medical teamwork improvement interventions have occurred in hospitals, and more efforts are needed to integrate them into ambulatory care settings. In 2014, Affiliates Risk Management Services, Inc. (ARMS), the risk management services organization for a large network of reproductive health care organizations in the United States, launched a voluntary 5-year initiative to implement a medical teamwork system in this network using the TeamSTEPPS model. This article describes the ARMS initiative and progress made during the first 2 years, including lessons learned. The ARMS TeamSTEPPS program consists of the following components: preparation of participating organizations, TeamSTEPPS master training, implementation of teamwork improvement programs, and evaluation. We used self-administered questionnaires to assess satisfaction with the ARMS program and with the master training course. In the first 2 years, 20 organizations enrolled. Participants found the preparation phase valuable and were highly satisfied with the master training course. Although most attendees felt that the course imparted the knowledge and tools critical for TeamSTEPPS implementation, they identified time restraints and competing initiatives as potential barriers. The project team has learned valuable lessons about obtaining buy-in, consolidating the change teams, making the curriculum relevant, and evaluation. Ambulatory care settings require innovative approaches to integration of teamwork improvement systems. Evaluating and sharing lessons learned will help to hone best practices as we navigate this new frontier in the field of patient safety. © 2017 American Society for Healthcare Risk Management of the American Hospital Association.

  16. Walking Clinic in ambulatory surgery--A patient based concept: A Portuguese pioneer project.

    PubMed

    Vinagreiro, M; Valverde, J N; Alves, D; Costa, M; Gouveia, P; Guerreiro, E

    2015-06-01

    Walking Clinic is an innovative, efficient and easily reproducible concept adapted to ambulatory surgery. It consists of a preoperative single day work-up, with a surgeon, an anesthetist and a nurse. The aim of this study was to evaluate patient satisfaction and its determinants. A survey was applied to 171 patients (101 of the Walking Clinic group and 70 not engaged in this new concept). Patient satisfaction was assessed evaluating five major questionnaire items: secretariat (quality of the information and support given), physical space (overall comfort and cleanliness), nurses and medical staff (willingness and expertise), and patients (waiting time until pre-operative consults and exams, waiting time until being scheduled for surgery, surgery day waiting time and postoperative pain control). Furthermore, overall assessment of the received treatment, and probability of patient recommending or returning to our ambulatory unit were also analyzed. Walking Clinic group had overall better results in the five major questionnaire items assessed, with statistical significance, except for the physical space. It also showed better results regarding the sub-items postoperative pain control, waiting time until being scheduled for surgery and surgery day waiting time. The results confirm better patient satisfaction with this new concept. The Walking Clinic concept complements all the tenets of ambulatory surgery, in a more efficient manner. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

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

    PubMed

    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.

  18. Hotel-based ambulatory care for complex cancer patients: a review of the University College London Hospital experience.

    PubMed

    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.

  19. Congruence of disposition after emergency department intubation in the National Hospital Ambulatory Medical Care Survey.

    PubMed

    Green, Steven M

    2013-04-01

    The National Hospital Ambulatory Medical Care Survey (NHAMCS) includes a large nationally representative sample of emergency department (ED) visits that is widely used for research. This study investigates the frequency of apparent NHAMCS disposition discrepancies for visits with intubation. Using 10 years' worth of NHAMCS data composed of 348,367 ED visits, those recorded as including intubation were evaluated for congruence of disposition, which was expected to be either death or admission to a critical care unit. Of the 875 ED patients recorded as having intubation performed, 27% had incompatible dispositions: 81 (9%) were recorded as discharged and 153 (17%) as admitted to a non-critical care unit. Cross-reference with free text chief complaint descriptions and International Classification of Diseases, Ninth Revision diagnoses codes indicated errors in recording both intubation and admission. One fourth of NHAMCS ED visits with intubation have an ED disposition incompatible with this procedure. Copyright © 2012. Published by Mosby, Inc.

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

    PubMed

    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. [Ambulatory blood pressure profiles of patients with permanent or occasional hypertension. Correlation with clinical data].

    PubMed

    Herpin, D; Amiel, A; Boutaud, P; Ciber, M A; Demange, J

    1987-06-01

    Ambulatory blood pressure (BP) recording was performed in 57 untreated hypertensive patients by means of the "Spacelabs" non-invasive apparatus. Patients were divided into two groups according to BP measurements previously made during medical consultation. Group I comprised 25 "permanently hypertensive" patients (diastolic BP always above 95 mmHg) and group II, 32 "occasionally hypertensive" patients (diastolic BP sometimes normal, sometimes above 95 mmHg). The same circadian rhythm was observed in both groups. The mean ambulatory BP level was significantly higher (p less than 0.001) in group I patients than in group II patients, either over the whole of the 24-hour period (142.0/88.0 versus 122.7/75.3 mmHg), or in day time (149.0/92.5 versus 128.2/78.9 mmHg) or at night (128.0/80.1 versus 111.5/68.0 mmHg). In contrast, there did not seem to be any significant difference between the two groups in relative long-term variability of BP, expressed as the standard deviation/mean BP values ratio. Comparison with clinical data showed that BP values measured during consultation (160/103 mmHg in group I, 143/94 mmHg in group II) were higher than ambulatory values and, chiefly, that there was very poor correlation between the two measurement methods, precluding any extrapolation. Automatic ambulatory BP recording provides for more accurate evaluation of hypertensive patients, enabling emotional "artefacts" to be excluded and patients "reactivity" to their socio-professional environment to be assessed. However, in the absence of sufficient epidemiological data, doctors should not feel authorized to base their therapeutic decisions on the sole data supplied by ambulatory BP recordings.

  2. Psychometric properties of the Persian version of the Ambulatory Care Learning Educational Environment Measure (ACLEEM) questionnaire, Shiraz, Iran.

    PubMed

    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

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

    PubMed

    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-<18 years) with long-term therapy of at least one 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.

  4. Procedures in ambulatory care. Which family physicians do what in southwestern Ontario?

    PubMed Central

    Wetmore, S. J.; Agbayani, R.; Bass, M. J.

    1998-01-01

    OBJECTIVE: To determine how often family physicians perform 12 ambulatory care procedures and factors associated with procedure performance. DESIGN: Mailed, self-administered survey. The survey was conducted according to the Dillman Total Design method. SETTING: Family physicians' offices in London, Ont, and in surrounding communities. PARTICIPANTS: A total of 395 family physicians practising within the London area were mailed surveys, 237 in London and 158 outside London. Response rates were 80.6% and 75.9%, respectively. Nonresponders did not differ significantly from responders in sex but included more solo practitioners. MAIN OUTCOME MEASURES: Performance of ambulatory care procedures, sex, and practice characteristics of participant family physicians. RESULTS: For all responders, activities significantly associated with procedure performance were delivering babies, managing psychological problems, working emergency, and teaching. Mean total procedure scores ranged from 6.55 for managing psychological problems to 7.68 for working emergency. Sex-specific analysis showed that practice location and years in practice were significant factors for female but not for male family physicians. Mean total procedure scores for female physicians were 7.06 (outside London) and 4.74 (in London). CONCLUSIONS: Factors associated with procedure performance for family physicians in and around London included delivering babies, working in emergency, managing psychological problems, and teaching. Practice location was a significant factor for only female family physicians; those practising outside London performed procedures more than their urban counterparts and at similar rates to male physicians. PMID:9559192

  5. Clinical prediction model to identify vulnerable patients in ambulatory surgery: towards optimal medical decision-making.

    PubMed

    Mijderwijk, Herjan; Stolker, Robert Jan; Duivenvoorden, Hugo J; Klimek, Markus; Steyerberg, Ewout W

    2016-09-01

    Ambulatory surgery patients are at risk of adverse psychological outcomes such as anxiety, aggression, fatigue, and depression. We developed and validated a clinical prediction model to identify patients who were vulnerable to these psychological outcome parameters. We prospectively assessed 383 mixed ambulatory surgery patients for psychological vulnerability, defined as the presence of anxiety (state/trait), aggression (state/trait), fatigue, and depression seven days after surgery. Three psychological vulnerability categories were considered-i.e., none, one, or multiple poor scores, defined as a score exceeding one standard deviation above the mean for each single outcome according to normative data. The following determinants were assessed preoperatively: sociodemographic (age, sex, level of education, employment status, marital status, having children, religion, nationality), medical (heart rate and body mass index), and psychological variables (self-esteem and self-efficacy), in addition to anxiety, aggression, fatigue, and depression. A prediction model was constructed using ordinal polytomous logistic regression analysis, and bootstrapping was applied for internal validation. The ordinal c-index (ORC) quantified the discriminative ability of the model, in addition to measures for overall model performance (Nagelkerke's R (2) ). In this population, 137 (36%) patients were identified as being psychologically vulnerable after surgery for at least one of the psychological outcomes. The most parsimonious and optimal prediction model combined sociodemographic variables (level of education, having children, and nationality) with psychological variables (trait anxiety, state/trait aggression, fatigue, and depression). Model performance was promising: R (2)  = 30% and ORC = 0.76 after correction for optimism. This study identified a substantial group of vulnerable patients in ambulatory surgery. The proposed clinical prediction model could allow healthcare

  6. MISSED WELL-CHILD CARE VISITS, LOW CONTINUITY OF CARE, AND RISK FOR AMBULATORY CARE SENSITIVE HOSPITALIZATIONS IN YOUNG CHILDREN

    PubMed Central

    Tom, Jeffrey; Tseng, Chien-Wen; Davis, James; Solomon, Cam; Zhou, Chuan; Mangione-Smith, Rita

    2013-01-01

    Objectives To determine if adherence to the recommended well-child care (WCC) visit schedule, independent of continuity of care (COC), is associated with lower risk for Ambulatory Care Sensitive Hospitalizations (ACSH) and whether this association varies by chronic disease status. Design Population-based, retrospective cohort study Setting Hawaii’s largest health plan from 1999 to 2006 Patients/Participants 36,944 children ≤ 3.5 years-old who were eligible if they were enrolled prior to 2 months-old, had ≥ 4 outpatient visits during the study period, and had an enrollment period that overlapped with ≥ 1 WCC visit interval. Main Exposure(s) WCC visit adherence and COC Index Main Outcome Measure(s) Risk for ACSH (Hazard Ratio [HR]) Results Overall, 8,921 (24%) children had ≥ 1 chronic disease. The proportions of ACSH among healthy children versus those with ≥ 1 chronic disease were 3% (n= 751) and 7% (n= 645), respectively. For children with chronic disease, those with the lowest WCC visit adherence (0–25%) had 1.9 times (HR: 1.9, 95% Confidence Interval [CI]: 1.5–2.5) the risk of ACSH compared to those in the highest category (75–100%). The risk of ACSH for children with chronic disease who fell into the lowest COC category (0–0.25) was 2.4 times (HR 2.4, 95% CI: 1.7–3.5) higher than for those who fell into the highest category (0.75–1.0). Conclusions For children with chronic disease, both low WCC visit adherence and COC are independently associated with an increased risk of ACSH. Providing access to a consistent source of primary care appears important for this vulnerable population. PMID:21041598

  7. Various Manifestations of Hyperthyroidism in an Ambulatory Clinic: Case Studies

    PubMed Central

    Tripp, Warren; Rao, Vijaya; Creary, Ludlow B.

    1987-01-01

    This study reviews five cases of women with hyperthyroidism, three black women and two Hispanic women. Initially, two patients presented with voice changes, weight loss, and increased appetite. Only two patients presented with classical symptoms of hyperthyroidism. Examination showed all patients had diffusely enlarged thyroids and exaggerated reflexes. Two patients showed Graves' opthalmopathy. These cases document the variety of presentations of hyperthyroidism. Hence, a high index of suspicion must exist for this disease, even in the absence of a number of the classical manifestations of hyperthyroidism. When patients present to primary care centers with a constellation of symptoms, an examination of the thyroid gland is essential. PMID:3694696

  8. Ambulatory BP monitoring and clinic BP in predicting small-for-gestational-age infants during pregnancy.

    PubMed

    Eguchi, K; Ohmaru, T; Ohkuchi, A; Hirashima, C; Takahashi, K; Suzuki, H; Kario, K; Matsubara, S; Suzuki, Mitsuaki

    2016-01-01

    The significance of ambulatory blood pressure (ABP) monitoring during pregnancy has not been established. We performed a prospective study to elucidate whether ABP measures are associated with small-for-gestational-age birth weight (SGA). We studied 146 pregnant women who were seen for maternal medical checkups or suspected hypertension. ABP monitoring was performed for further assessment of hypertension. The outcome measure was SGA. The subjects were classified by their medical history and ABP as having preeclampsia or gestational hypertension (n=68 cases), chronic hypertension (n=48) or white-coat hypertension (n=30). There were 50 (34.2%) cases of SGA by the fetal growth reference standard. In multivariable logistic regression analyses adjusting for age, body mass index, the presence of prior pregnancy, current smoking habit and the use of antihypertensive medications, 24-h SBP (per 10 mm Hg (odds ratio (OR): 1.74; 95% confidence interval (CI): 1.28-2.38; P<0.001)) was more closely associated with SGA than clinic BP (OR: 1.40; 95% CI: 0.92-2.13; P=0.11). The results were essentially the same if 24-h BP was replaced by awake or sleep SBP. Ambulatory diastolic BP showed the same tendency. However, abnormal circadian rhythm was not associated with the outcome. In conclusion, ambulatory BP monitoring measures performed during pregnancy were more closely associated with SGA than clinic BP.

  9. [csapAIH: a function to classify ambulatory care sensitive conditions in the statistical software R].

    PubMed

    Nedel, Fúlvio Borges

    2017-01-01

    Hospitalizations due to ambulatory care sensitive conditions (ACSC) are an indirect indicator of primary health care. A package in the R program was developed in order to automatize the classification of codes of the International Statistical Classification of Diseases and Related Health Problems - 10th Revision (ICD-10), according to the Brazilian list of ACSC, and provide functionalities for the management of the "reduced files" of the inpatient hospital authorization (AIH). The csapAIH package contains a homonym function, which reads the data according to its nature (file or data frame with AIH structure, or a factor with ICD-10 codes) and returns, according to defined options, a databank or vector containing the classification for the hospitalization. This article presents the package and the function csapAIH, its installation mode and use, and examples of its functionalities, which may add quickness, precision and validity to the research of ACSC in Brazil.

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

    PubMed

    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.

  11. Addressing pediatric obesity in ambulatory care: where are we and where are we going?

    PubMed Central

    Manders, Aaron J.; Perdomo, Joanna E.; Ireland, Kathy A.; Barlow, Sarah E.

    2017-01-01

    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. PMID:27048522

  12. Assessing the Functional Status of Older Cancer Patients in an Ambulatory Care Visit

    PubMed Central

    Overcash, Janine

    2015-01-01

    Functional status assessment is a useful and essential component of the complete history and physical exam of the older patient diagnosed with cancer. Functional status is the ability to conduct activities that are necessary for independence and more executive activities, such as money management, cooking, and transportation. Assessment of functional status creates a portal into interpreting the health of in older persons. Understanding limitations and physical abilities can help in developing cancer treatment strategies, patient/family teaching needs, and in-home services that enhance patient/family care. This article will review the benefits of functional assessment, instruments that can be used during an ambulatory care visit, and interventions that can address potential limitations. PMID:27417801

  13. Interventions and targets aimed at improving quality in inflammatory bowel disease ambulatory care

    PubMed Central

    Weizman, Adam V; Nguyen, Geoffrey C

    2013-01-01

    Over the past decade, there has been increasing focus on improving the quality of healthcare delivered to patients with chronic diseases, including inflammatory bowel disease. Inflammatory bowel disease is a complex, chronic condition with associated morbidity, health care costs, and reductions in quality of life. The condition is managed primarily in the outpatient setting. The delivery of high quality of care is suboptimal in several ambulatory inflammatory bowel disease domains including objective assessments of disease activity, the use of steroid-sparing agents, screening prior to anti-tumor necrosis factor therapy, and monitoring thiopurine therapy. This review outlines these gaps in performance and provides potential initiatives aimed at improvement including reimbursement programs, quality improvement frameworks, collaborative efforts in quality improvement, and the use of healthcare information technology. PMID:24151356

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

    PubMed

    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.

  15. In-Clinic Blood Pressure Prediction of Normal Ambulatory Blood Pressure Monitoring in Pediatric Hypertension Referrals.

    PubMed

    Johnson, Philip K; Ferguson, Michael A; Zachariah, Justin P

    2016-07-01

    Since younger patients have low pretest probability of hypertension and are susceptible to reactive and masked hypertension, ambulatory blood pressure monitoring (ABPM) can be useful. To better target use in referred patients, we sought to define in-clinic systolic blood pressure (SBP) measures that predicted normal ABPM and target end organ damage. Data were collected on consecutive patients referred for high BP undergoing an ambulatory BP monitor from 2010 to 2013 (n = 248, 33.9% female, mean age 15.5 ± 3.6 years). Candidate in-clinic predictors were systolic maximum, minimum, or average BPs obtained by auscultative, oscillometric, or both. Multivariable logistic regression models were used to determine the prediction of normal ABPM by in-clinic BP predictors. Separate models considered predicting left ventricular hypertrophy (LVH) by in-clinic SBP vs. ABPM-defined hypertension. Identified predictor utility was tested with receiver operator characteristic curves. Maximum (OR 0.97 [95% CI 0.94-0.99]; P = .047), minimum (0.96 [0.94-0.99]; P = .002), and average (0.97 [0.95-1.00]; P = .04) in-clinic auscultative SBP predicted normal ABPM. Each had a c-statistic of 0.58. LVH was associated with in-clinic auscultative minimum SBP treated continuously (1.05, [1.01-1.10], P = .01) or dichotomized at the 90th percentile (8.23, [1.48-45.80], P = .02), as well as ABPM-defined hypertension (3.31, [1.23-8.91], P = .02). Both predictors had poor sensitivity and specificity. In youth, normal auscultative in-clinic systolic blood pressure indices weakly predicted normal ambulatory blood pressure and target end organ damage. © 2016 Wiley Periodicals, Inc.

  16. [Medical care unit -- a suitable instrument for ambulatory patient-adequate care and performance-related remuneration].

    PubMed

    Rudolph, P; Isensee, D; Gerlach, E; Gross, H

    2013-02-01

    The question of whether a medical care unit is an appropriate tool for outpatient care has been discussed for a long time. Our aim is to investigate whether the MCU is an effective instrument for outpatient care and adequate performance-related remuneration. This retro- and prospective overview of the work included statements on legal foundations for medical care units, for reimbursement of services in medical care units, the development of medical care centres in Germany and a listing of the specific advantages and disadvantages of an MCU. This article focuses on the generally applicable facts and complements them with examples from general, visceral and vascular surgery. The main quantitative data on medical centre statistics come from different publications of the National Association of Statutory Health Insurance for Physicians. From a legal point of view the instrument MCU allows the participating of ambulatory and stationary care in the framework of medical care contracts. This has been especially extended for stationary applications, including the spectrum of possibilities that can contribute under certain circumstances for the provision of medical care in underdeveloped regions. Freelancers can benefit primarily from financial risk and minimising bureaucratic routine. The remuneration for services performed in the MCU is analogous to that of other ambulatory care providers. Basically, there are no disadvantages, but a greater design freedom and opportunities for the generation of aggregates are visible. The number of MCU in Germany has quadrupled in the last five years, indicating an establishment of an outpatient care landscape. MCU offers from the patient's perspective, providers and policy specific advantages and disadvantages. Indeed the benefits outweigh the disadvantages, but this is not yet verified by qualitative studies. The question of the appropriateness of medical care units as outpatient care instrumentation must be considered differentially

  17. Do hospitalisations for ambulatory care sensitive conditions reflect low access to primary care? An observational cohort study of primary care usage prior to hospitalisation.

    PubMed

    Vuik, Sabine I; Fontana, Gianluca; Mayer, Erik; Darzi, Ara

    2017-08-21

    To explore whether hospitalisations for ambulatory care sensitive conditions (ACSCs) are associated with low access to primary care. Observational cohort study over 2008 to 2012 using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases. English primary and secondary care. A random sample of 300 000 patients. Emergency hospitalisation for an ACSC. Over the long term, patients with ACSC hospitalisations had on average 2.33 (2.17 to 2.49) more general practice contacts per 6 months than patients with similar conditions who did not require hospitalisation. When accounting for the number of diagnosed ACSCs, age, gender and GP practice through a nested case-control method, the difference was smaller (0.64 contacts), but still significant (p<0.001).In the short-term analysis, measured over the 6 months prior to hospitalisation, patients used more GP services than on average over the 5 years. Cases had significantly (p<0.001) more primary care contacts in the 6 months before ACSC hospitalisations (7.12, 95% CI 6.95 to 7.30) than their controls during the same 6 months (5.57, 95% CI 5.43 to 5.72). The use of GP services increased closer to the time of hospitalisation, with a peak of 1.79 (1.74 to 1.83) contacts in the last 30 days before hospitalisation. This study found no evidence to support the hypothesis that low access to primary care is the main driver of ACSC hospitalisations. Other causes should also be explored to understand how to use ACSC admission rates as quality metrics, and to develop the appropriate interventions. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  18. Nonattendance in pediatric pulmonary clinics: an ambulatory survey

    PubMed Central

    Goldbart, Aviv D; Dreiher, Jacob; Vardy, Daniel A; Alkrinawi, Soliman; Cohen, Arnon D

    2009-01-01

    Background Nonattendance for scheduled appointments disturbs the effective management of pediatric pulmonary clinics. We hypothesized that the reasons for non-attendance and the necessary solutions might be different in pediatric pulmonary medicine than in other pediatric fields. We therefore investigated the factors associated with nonattendance this field in order to devise a corrective strategy. Methods The effect of age, gender, ethnic origin, waiting time for an appointment and the timing of appointments during the day on nonattendance proportion were assessed. Chi-square tests were used to analyze statistically significant differences of categorical variables. Logistic regression models were used for multivariate analysis. Results A total of 1190 pediatric pulmonology clinic visits in a 21 month period were included in the study. The overall proportion of nonattendance was 30.6%. Nonattendance was 23.8% when there was a short waiting time for an appointment (1–7 days) and 36.3% when there was a long waiting time (8 days and above) (p-value < 0.001). Nonattendance was 28.7% between 8 a.m. to 3 p.m. and 37.5% after 3 p.m. (p = 0.007). Jewish rural patients had 15.4% nonattendance, Jewish urban patients had 31.2% nonattendance and Bedouin patients had 32.9% nonattendance (p < 0.004). Age and gender were not significantly associated with nonattendance proportions. A multivariate logistic regression model demonstrated that the waiting time for an appointment, time of the day, and the patients' origin was significantly associated with nonattendance. Conclusion The factors associated with nonattendance in pediatric pulmonary clinics include the length of waiting time for an appointment, the hour of the appointment within the day and the origin of the patient. PMID:19366453

  19. Patients as reliable reporters of medical care process. Recall of ambulatory encounter events.

    PubMed

    Brown, J B; Adams, M E

    1992-05-01

    This study explores the reliability of a data source on the quality and content of care rarely used in studies comparing the performance of health care organizations, that is, patient reports obtained from surveys. Evidence of patient survey reliability and validity and report data on patient reporting accuracy were reviewed for ten events that may have occurred during an initial health assessment for new adult enrollees of a health maintenance organization (HMO). Reports of 380 patients obtained through telephone survey were compared with medical records. For chest radiograph, mammogram, and electrocardiogram (EKG), patient reports exhibited both sensitivity and specificity. For serum cholesterol test, patients proved to be sensitive but not specific reporters. For blood pressure measurement, stool kit, and rectal examination, false negative rates were low (less than or equal to 0.10); they were somewhat higher for breast self-examination instruction and pelvic examination (0.21 and 0.22, respectively). Only for testicular self-examination instruction did patient reports fail to confirm medical record documentation (false negative rate = 0.53). Multivariate analysis showed a small association between increasing patient age and decreasing confirmation. Gender did not affect reporting ability, and agreement did not deteriorate over a 2- to 3-month postencounter interval. Patient reports appear to merit greater use in comparative studies of technical quality of care. Key words: quality of health care; quality assurance; health care; ambulatory care; patient recall; patient reports.

  20. Recent trends in antibiotic prescriptions for acute respiratory tract infections in pediatric ambulatory care in Taiwan, 2000-2009: A nationwide population-based study.

    PubMed

    Lee, Ming-Luen; Cho, Ching-Yi; Hsu, Chien-Lun; Chen, Chun-Jen; Chang, Lo-Yi; Lee, Yu-Sheng; Soong, Wen-Jue; Jeng, Mei-Jy; Wu, Keh-Gong

    2016-08-01

    Antibiotic resistance is a global problem, and the inappropriate overuse of antibiotics is the major cause. Among children seeking medical help, acute respiratory tract infections (ARTIs) are the most common tentative diagnosis made by physicians and the leading condition for which antibiotics are prescribed. This study aimed to examine the trends of prescribing antibiotics in pediatric ambulatory care in Taiwan over a 10-year period. Children younger than 18 years old and being diagnosed as having ARTIs [International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 460, 465, and 466] during ambulatory visits from 2000 to 2009 were retrieved from the systematic random sampling datasets of the National Health Insurance Research Database (NHIRD) in Taiwan. The annual and monthly case numbers were recorded and the children's demographic characteristics, including sex, age, seasonality, location, level of medical institution, physician specialty, and their ambulatory prescriptions of antibiotics were collected and analyzed. Among 565,065 enrolled ambulatory children, 39,324 were prescribed antibiotics. The average antibiotics prescription rate was 7.0% during the 10-year period. There were marked descending trends in case numbers and antibiotic dispensing rates from 2000 to 2009. Female patients, elder ages (≥6 years old), summer and autumn, middle and southern areas of Taiwan, medical centers and regional hospitals, and physicians of pediatric specialty were associated with significantly lower antibiotic dispensing rates than other conditions (p < 0.05). The 10-year antibiotics prescription rate in ambulatory children with ARTIs was 7.0% and it decreased gradually from 2000 to 2009 in Taiwan. Through understanding the annual trends in antibiotic prescriptions, it may be possible to design interventions to improve the judicious use of antibiotics in children. Copyright © 2014. Published by Elsevier B.V.

  1. Effect of Home Monitoring via Mobile App on the Number of In-Person Visits Following Ambulatory Surgery: A Randomized Clinical Trial.

    PubMed

    Armstrong, Kathleen A; Coyte, Peter C; Brown, Mitchell; Beber, Brett; Semple, John L

    2017-07-01

    In the age of information and patient-centered care, new methods of delivering postoperative care must be developed and evaluated. To determine whether follow-up care delivered via a mobile app can be used to avert in-person follow-up care visits compared with conventional, in-person follow-up care in the first 30 days following ambulatory surgery. A randomized clinical trial was conducted from February 1 to August 31, 2015, among ambulatory patients undergoing breast reconstruction at an academic ambulatory care hospital. Patients were randomly assigned to receive follow-up care via a mobile app or at an in-person visit during the first 30 days after the operation. Analysis was intention-to-treat. The primary end point was the number of in-person follow-up visits during the first 30 days after the operation. Secondary end points were the number of telephone calls and emails to health care professionals, patient-reported convenience and satisfaction scores, and rates of complications. Of the 65 women in the study (mean [SD] age, 47.7 [13.4] years), 32 (49%) were in the mobile app group, and 33 (51%) were in the in-person follow-up care group. Those in the mobile app group attended a mean of 0.66 in-person visits, vs 1.64 in-person visits in the in-person follow-up care group, for a difference of 0.40 times fewer in-person visits (95% CI, 0.24-0.66; P < .001) and sent more emails to their health care professionals during the first 30 days after the operation (mean, 0.65 vs 0.15; incidence rate ratio, 4.13; 95% CI, 1.55-10.99; P = .005) than did patients in the in-person follow-up care group. This statistically significant difference was maintained at 3 months postoperatively. The mobile app group reported higher convenience scores than the in-person follow-up care group (incidence rate ratio, 1.39; 95% CI, 1.09-1.77; P = .008). There was no difference between groups in the number of telephone communications, satisfaction scores, or complication rates

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

    PubMed Central

    Lynn, An-Min; Lai, Li-Jung; Lin, Ming-Hwai; Chen, Tzeng-Ji; Hwang, Shinn-Jang; Wang, Peng-Hui

    2015-01-01

    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. PMID:26086705

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

    PubMed Central

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

    PubMed

    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.

  5. Social interactions between veterinary medical students and their teachers in an ambulatory clinic setting in Finland.

    PubMed

    Koskinen, Heli I

    2010-01-01

    In this study, the social interactions between students and their teachers in an ambulatory clinic setting were investigated using Bales's interaction process analysis framework. Observational data were collected during five small-group sessions. The observations were quantified, and the behaviors of students and teachers were compared statistically. This study demonstrated that the interaction between students and their teachers was for the most part equal and could be characterized as "positively task oriented." The study has implications for veterinary educators wishing to use social psychology frameworks to assess the quality of learning in small-group clinical setting.

  6. Association of Income Inequality With Pediatric Hospitalizations for Ambulatory Care-Sensitive Conditions.

    PubMed

    Bettenhausen, Jessica L; Colvin, Jeffrey D; Berry, Jay G; Puls, Henry T; Markham, Jessica L; Plencner, Laura M; Krager, Molly K; Johnson, Matthew B; Queen, Mary Ann; Walker, Jacqueline M; Latta, Grant M; Riss, Robert R; Hall, Matt

    2017-06-05

    The level of income inequality (ie, the variation in median household income among households within a geographic area), in addition to family-level income, is associated with worsened health outcomes in children. To determine the influence of income inequality on pediatric hospitalization rates for ambulatory care-sensitive conditions (ACSCs) and whether income inequality affects use of resources per hospitalization for ACSCs. This retrospective, cross-sectional analysis used the 2014 State Inpatient Databases of the Healthcare Cost and Utilization Project of 14 states to evaluate all hospital discharges for patients aged 0 to 17 years (hereafter referred to as children) from January 1 through December 31, 2014. Using the 2014 American Community Survey (US Census), income inequality (Gini index; range, 0 [perfect equality] to 1.00 [perfect inequality]), median household income, and total population of children aged 0 to 17 years for each zip code in the 14 states were measured. The Gini index for zip codes was divided into quartiles for low, low-middle, high-middle, and high income inequality. Rate, length of stay, and charges for pediatric hospitalizations for ACSCs. A total of 79 275 hospitalizations for ACSCs occurred among the 21 737 661 children living in the 8375 zip codes in the 14 included states. After adjustment for median household income and state of residence, ACSC hospitalization rates per 10 000 children increased significantly as income inequality increased from low (27.2; 95% CI, 26.5-27.9) to low-middle (27.9; 95% CI, 27.4-28.5), high-middle (29.2; 95% CI, 28.6-29.7), and high (31.8; 95% CI, 31.2-32.3) categories (P < .001). A significant, clinically unimportant longer length of stay was found for high inequality (2.5 days; 95% CI, 2.4-2.5 days) compared with low inequality (2.4 days; 95% CI, 2.4-2.5 days; P < .001) zip codes and between charges ($765 difference among groups; P < .001). Children living in areas of high income

  7. Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner.

    PubMed

    Conrad, Dianne; Hanson, Patricia A; Hasenau, Susan M; Stocker-Schneider, Julia

    2012-07-01

    This study identified the perceived user barriers to documentation of nursing practice utilizing standardized nursing language (SNL) in the electronic health record (EHR) by ambulatory care nurse practitioners (NPs). A researcher-developed survey was sent to a randomized sample of ambulatory care NPs in the United States who belonged to the American Academy of Nurse Practitioners (n= 1997). Surveyed ambulatory care NPs placed a higher value on documenting medical care versus nursing care. Only 17% of respondents currently use SNL and 30% believe that SNL is not important or appropriate to document NP practice. Barriers to using SNL in EHRs included lack of reimbursement for nursing documentation, lack of time to document, and lack of availability of SNL in electronic records. Respondents identified NP practice as a blend of medical as well as nursing care but NPs have not embraced the current SNLs as a vehicle to document the nursing component of their care, particularly in EHRs. Until these barriers are addressed and discreet data in the form of SNL are available and utilized in the EHR, the impact of the NPs care will be unidentifiable for outcomes reporting. ©2012 The Author(s) Journal compilation ©2012 American Academy of Nurse Practitioners.

  8. Mat Pilates training reduced clinical and ambulatory blood pressure in hypertensive women using antihypertensive medications.

    PubMed

    Martins-Meneses, Daniele Tavares; Antunes, Hanna Karen Moreira; de Oliveira, Nara Rejane Cruz; Medeiros, Alessandra

    2015-01-20

    Physical exercise has been used in the treatment of hypertension. However, there are few methods researched and shown beneficial for treatment of hypertension. The objective was to evaluate the effect of Mat Pilates training (MP) on blood pressure (BP) of hypertensive women medicated with antihypertensive drugs. 44 hypertensive women (50.5 ± 6.3 years age), treated with medication for blood pressure and, uninvolved in structured exercise program were distributed into two groups: Training Group (TG) and Control Group (CG). TG performed 60-minute sessions of MP, twice a week for 16 weeks. CG was requested to maintain daily activities without exercise training. The following variables were evaluated during the pre- and post-experimental periods: clinical and ambulatory BP, heart rate (HR) and double product (DP), besides body mass, height, body mass index, waist and hip circumferences, flexibility, and right and left hand strengths. TG showed statistically significant improvements (p<0.05) within and between-groups for the systolic, diastolic and mean BP in all moments evaluated (clinical, 24h, awake and asleep). Besides that, TG showed improvements in height, waist and hip circumferences, flexibility, right and left hand strengths and clinical DP. The other variables in TG, as well as all variables in the CG didn't show significant changes. In hypertensive women using antihypertensive medications, MP reduces clinical and ambulatory BP. These results support the recommendation of MP as a non-drug treatment for hypertension. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  9. 42 CFR 410.165 - Payment for rural health clinic services and ambulatory surgical center services: Conditions.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Payment for rural health clinic services and... (SMI) BENEFITS Payment of SMI Benefits § 410.165 Payment for rural health clinic services and ambulatory surgical center services: Conditions. (a) Medicare Part B pays for covered rural health clinic...

  10. Anesthesiologists' practice patterns for treatment of postoperative nausea and vomiting in the ambulatory Post Anesthesia Care Unit

    PubMed Central

    Macario, Alex; Claybon, Louis; Pergolizzi, Joseph V

    2006-01-01

    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-dose the 5-HT3-antagonist

  11. Health literacy and interpersonal interactions as predictors of maternal perception of ambulatory care for low-income, Latino children.

    PubMed

    Fry-Bowers, Eileen K; Maliski, Sally; Lewis, Mary Ann; Macabasco-O'Connell, Aurelia; Dimatteo, Robin

    2013-05-01

    This study explores whether maternal HL (MHL) and maternal perception of health care provider (HCP) interpersonal interactions predict maternal perception of quality of pediatric ambulatory care received. This cross-sectional study included 124 low-income Latina mothers of children 3 months to 4 years. Maternal HL, perception of maternal-HCP interpersonal interactions, and perception of pediatric ambulatory care were measured using well-validated surveys. In adjusted hierarchical regression models, HCP fail to speak clearly (β=-.225, 95% CI -13.998, -1.960, p=.01) and explain results (β=.344, 95% CI 3.480, 13.010, p=.001) predicted perception of quality of developmental guidance received. Explaining results (β=.422, 95% CI 5.700, 14.089, p=<.001), working out treatment together (β=.441, 95% CI 6.657, 13.624, p<.001) and MHL (β=-.301, 95% CI -7.161, -2.263, p<.001) predicted perception of family centeredness of care. Speaking with clarity, explaining results fully and working with the mother to determine a child's plan of care is most predictive of whether she feels her child is receiving high quality pediatric ambulatory care services. Interventions that target mother and provider interaction may improve perception of care. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

  12. Universal cholesterol screening of children in community-based ambulatory pediatric clinics.

    PubMed

    Wilson, Don P; Davis, Sharon; Matches, Sarah; Shah, Deep; Leung-Pineda, Van; Mou, Margaret; Hamilton, Luke; McNeal, Catherine J; Bowman, W Paul

    2015-01-01

    Early identification and treatment of individuals with elevated levels of atherogenic cholesterol have been shown to be effective and safe in reducing morbidity and mortality, especially in familial hypercholesterolemia. To better inform providers and identify children and adolescents at risk of premature cardiovascular disease, in November 2011, the National Heart, Lung, and Blood Institute (NHLBI) published guidelines recommending cholesterol screening of all children aged between 9 to 11 and 17 to 21 years regardless of the child's general health or the presence or the absence of cardiovascular disease risk factors. To compare the number of 9- to 11-year-old children screened for hypercholesterolemia in 5 community-based ambulatory pediatric clinics before and after publication of the NHLBI's guidelines. Practice demographics, screening frequency, and test results for each clinic were collected before and after publication of the NHLBI's recommendation. Provider education was provided between measures. Of all eligible 9- to 11-year-old children, 489 (17.1%) were screened before and 686 (20.1%) after the NHLBI's guidelines and provider education. Baseline rates of lipid screening for the 5 community-based ambulatory pediatric clinics were higher than those previously reported and increased significantly after publication of the NHLBI's recommendations and provider education. However, overall screening rates remained low. Given the high prevalence of premature cardiovascular disease associated with atherogenic cholesterol, especially familial hypercholesterolemia, additional strategies are needed to improve screening rates. Copyright © 2015 National Lipid Association. Published by Elsevier Inc. All rights reserved.

  13. Isolated clinical hypertension diagnosis: self-home BP, ambulatory BP monitoring, or both simultaneously?

    PubMed

    Coll de Tuero, Gabriel; Llibre, Joan Bayó; Poncelas, Antonio Rodriguez; Saumell, Carme Roca; Saez, Marc; Boreu, Quintí Foguet; Marcó, Narcís Salleres; Baqué, Antoni Dalfó; Sanz, M Rosa Senán; Fontanet, Mireia Ventura

    2011-02-01

    Self-blood pressure (BP) measurement (SBPM) and ambulatory BP measurement (ABPM) are suitable for the isolated clinical hypertension (ICH) or 'white-coat' hypertension diagnosis. However, patients with ICH have a different cardiovascular risk according to the measurement technique used for the diagnosis. To describe baseline cardiovascular risk of patients with hypertension and with ICH according to SBPM and daytime ABPM. Six hundred and sixty-four newly diagnosed and never treated patients with hypertension and with an average age of 59.3 years (standard deviation=12.0) were included (52% men) in this study. Clinical data, analytical data with urinary albumin excretion rate, estimated glomerular filtration rate, retinography, SBPM, and ABPM were performed. Cardiovascular risk was estimated from the European Society of Hypertension and Systemic Coronary Risk Evaluation tables. ICH prevalence varies according to the ambulatory measurement technique used: SBPM=24.2%, daytime ABPM=8.1, and 5.2% if criteria are required from both techniques. In the 403 patients with hypertension and who had SBPM and ABPM, the percentage of patients with high or very high baseline cardiovascular risk, falls progressively from 31.2% of patients with sustained hypertension to 20.0% of patients with ICH measured using SBPM, to 15.1% of patients with ICH measured using ABPM-day and to 9.5% of patients who present ICH using both techniques (P<0.005 for trend). The baseline results show that patients with hypertension and with ICH using SBPM and daytime ABPM are those who have a lower baseline cardiovascular risk and allow ICH to be defined on the basis of normal ambulatory readings using both techniques.

  14. Hospitalization for ambulatory care sensitive conditions at health insurance organization hospitals in Alexandria, Egypt.

    PubMed

    Mosallam, Rasha A; Guirguis, Wafaa W; Hassan, Mona Ha

    2014-01-01

    This study aimed at estimating the percentage of hospital discharges and days of care accounted for by Ambulatory Care Sensitive Conditions (ACSCs) at Health Insurance Organization (HIO) hospitals in Alexandria, calculating hospitalization rates for ACSCs among HIO population and identifying determinants of hospitalization for those conditions. A sample of 8300 medical records of patients discharged from three hospitals affiliated to HIO at Alexandria was reviewed. The rate of monthly discharges for ACSCs was estimated on the basis of counting number of combined ACSCs detected in the three hospitals and the hospitals' average monthly discharges. ACSCs accounted for about one-fifth of hospitalizations and days of care at HIO hospitals (21.8% and 20.8%, respectively). Annual hospitalization rates for ACSCs were 152.5 per 10,000 insured population. The highest rates were attributed to cellulitis/abscess (47.3 per 10,000 population), followed by diabetes complications and asthma (42.8 and 20.8 per 10,00 population). Logistic regression indicated that age, number of previous admissions, and admission department are significant predictors for hospitalization for an ACSC.

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

    PubMed

    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.

  16. Psychometric properties of the Persian version of the Ambulatory Care Learning Educational Environment Measure (ACLEEM) questionnaire, Shiraz, Iran

    PubMed Central

    Parvizi, Mohammad Mahdi; Amini, Mitra; Dehghani, Mohammad Reza; Jafari, Peyman; Parvizi, Zahra

    2016-01-01

    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: X2=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

  17. Risks to patient safety associated with implementation of electronic applications for medication management in ambulatory care--a systematic review.

    PubMed

    Carling, Cheryl L L; Kirkehei, Ingvild; Dalsbø, Therese Kristine; Paulsen, Elizabeth

    2013-12-05

    The objective was to find evidence to substantiate assertions that electronic applications for medication management in ambulatory care (electronic prescribing, clinical decision support (CDSS), electronic health record, and computer generated paper prescriptions), while intended to reduce prescribing errors, can themselves result in errors that might harm patients or increase risks to patient safety. Because a scoping search for adverse events in randomized controlled trials (RCTs) yielded few relevant results, we systematically searched nine databases, including MEDLINE, EMBASE, and The Cochrane Database of Systematic Reviews for systematic reviews and studies of a wide variety of designs that reported on implementation of the interventions. Studies that had safety and adverse events as outcomes, monitored for them, reported anecdotally adverse events or other events that might indicate a threat to patient safety were included. We found no systematic reviews that examined adverse events or patient harm caused by organizational interventions. Of the 4056 titles and abstracts screened, 176 full-text articles were assessed for inclusion. Sixty-one studies with appropriate interventions, settings and participants but without patient safety, adverse event outcomes or monitoring for risks were excluded, along with 77 other non-eligible studies. Eighteen randomized controlled trials (RCTs), 5 non-randomized controlled trials (non-R,CTs) and 15 observational studies were included. The most common electronic intervention studied was CDSS and the most frequent clinical area was cardio-vascular, including anti-coagulants. No RCTS or non-R,CTS reported adverse event. Adverse events reported in observational studies occurred less frequently after implementation of CDSS. One RCT and one observational study reported an increase in problematic prescriptions with electronic prescribing The safety implications of electronic medication management in ambulatory care have not been

  18. Clinical terminology support for a national ambulatory practice outcomes research network.

    PubMed

    Ricciardi, Thomas N; Lieberman, Michael I; Kahn, Michael G; Masarie, F E

    2005-01-01

    The Medical Quality Improvement Consortium (MQIC) is a nationwide collaboration of 74 healthcare delivery systems, consisting of 3755 clinicians, who contribute de-identified clinical data from the same commercial electronic medical record (EMR) for quality reporting, outcomes research and clinical research in public health and practice benchmarking. Despite the existence of a common, centrally-managed, shared terminology for core concepts (medications, problem lists, observation names), a substantial "back-end" information management process is required to ensure terminology and data harmonization for creating multi-facility clinically-acceptable queries and comparable results. We describe the information architecture created to support terminology harmonization across this data-sharing consortium and discuss the implications for large scale data sharing envisioned by proponents for the national adoption of ambulatory EMR systems.

  19. Home blood pressure vs. clinic blood pressure measurement-based follow up in type ii diabetics: Effect on 24-h ambulatory BP and albuminuria. Randomised trial.

    PubMed

    Martínez, María A; Garcia-Puig, Juan; Loeches, Maria P; Mateo, Maria C; Utiel, Isaías; Torres, Rosa

    2017-08-31

    To compare the efficacy of two strategies of blood pressure (BP) measurement-based follow-up in hypertension and albuminuria control. Multicentre, prospective, randomised, open trial with a parallel-group design. Nineteen primary care centres and a hospital clinic participated. Adult type 2 diabetics with systolic BP ≥140mmHg without relevant renal disease were randomised to one of two follow-up strategies: 1) standard follow up, with a clinic BP target <140/90mmHg and 2) self-monitoring home BP (SMHBP)-based follow up, with a BP target <135/85mmHg. Biochemical standard blood variables, albuminuria, and 24-h ambulatory BP monitoring were performed at entry, 12 and 24 months. The main outcome measurement was 24-h ambulatory systolic BP variation. Albuminuria change was analysed as a secondary outcome. 116 patients were analysed (mean age: 66.8 years). Mean systolic ambulatory 24- h BP change in two years was 3.9mmHg (95% CI 1.8-6.1). We did not find significant differences between both groups (p=0.706). Similarly, no differences were found when we compared other ambulatory BP values. Initial albuminuria was similar in both groups and did not significantly changed throughout the follow-up period. In type 2 diabetics without relevant nephropathy a SMHBP- based follow up was equivalent to a standard clinic-based BP follow up in BP and albuminuria control. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

  20. Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs.

    PubMed

    Gray, Bradley M; Vandergrift, Jonathan L; Johnston, Mary M; Reschovsky, James D; Lynn, Lorna A; Holmboe, Eric S; McCullough, Jeffrey S; Lipner, Rebecca S

    2014-12-10

    In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes. To measure associations between the original ABIM MOC requirement and outcomes of care. Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control. Quality measures were ambulatory care-sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care-sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars). Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs

  1. Economic impact of ambulatory care formulary restrictions at a large county health system.

    PubMed

    Centeno, Alexandra; Price, Venessa; Robinson, Natasha; Tomecko, G William; Sedam, Brian

    2013-07-15

    Study results documenting substantial cost savings achieved by an outpatient indigent-care pharmacy program through formulary modifications and optimized purchasing practices are presented. Wholesale purchasing data were retrospectively evaluated to compare drug expenditures before and after a large Florida hospital's adoption of a tiered formulary system for three ambulatory care facilities serving mostly uninsured patients. The outcomes assessed included the average cost per prescription and total medication purchases before and after implementation of the tiered formulary, which was phased in over several months and accompanied by intensive educational programs targeting physicians and pharmacy staff. Other outcomes included cost avoidance resulting from an increased emphasis on patient assistance program (PAP) enrollment and the use of "bulk replacement" arrangements for prescription replenishment. During a designated nine-month postimplementation period, the average cost per prescription declined by 4.7% (from $19.86 to $18.92) relative to the baseline value. Six-month spending decreases of 36-58% from prior-year levels were achieved in 7 of the 10 most-purchased drug classes, with an overall 25% decline in medication purchases. Cost avoidance due to more aggressive use of PAPs and bulk replacement programs also yielded substantial program savings. Formulary streamlining and other cost-control initiatives at an outpatient pharmacy program were associated with a decrease in the average cost per prescription of $0.94 over a nine-month period. The primary endpoint showed a potential annualized savings of approximately $1 million.

  2. Ambulatory care trends in Germany: a road toward more integration of care?

    PubMed

    Redaelli, Marcus; Meuser, Susanne; Stock, Stephanie

    2012-01-01

    Traditionally, Germany has a weak primary care system. In addition, the number of general practitioners (GPs) has declined in the past years. Main challenges are an aging population, disintegration of care, variations in care, an increase in chronic conditions, and a shortage of GPs especially in rural areas. Policy reacted by implementing financial incentives for GPs in rural areas and special GP training programs. Improvements in chronic care aim to better integrate care through Disease Management Programs, the electronic health card, and voluntary primary care schemes. The largest challenge to be addressed is the delegation of physician tasks to physician assistants.

  3. Female genital mutilation management in the ambulatory clinic setting: a case study and review of the literature

    PubMed Central

    Craven, Spencer; Kavanagh, Alex; Khavari, Rose

    2016-01-01

    A 31-year-old patient with obstructive voiding symptoms and apareunia in the setting of Type III female genital mutilation/cutting (FGM/C) is presented. The patient underwent ambulatory clinic defibulation to relieve her symptoms. FGM has been shown to have serious immediate complications and many chronic complications that greatly impact patients’ lives. Several case series have been published describing center-specific experience with defibulation procedures for Type III FGM/C. Here, we present the treatment of a patient with Type III FGM/C in an ambulatory urology clinic in the United States. PMID:27333917

  4. Role of Ambulatory and Home Blood Pressure Monitoring in Clinical Practice: A Narrative Review

    PubMed Central

    Shimbo, Daichi; Abdalla, Marwah; Falzon, Louise; Townsend, Raymond R.; Muntner, Paul

    2015-01-01

    Hypertension, a common cardiovascular disease (CVD) risk factor, is usually diagnosed and treated based on blood pressure readings obtained in the clinic setting. Blood pressure may differ considerably when measured in the clinic versus outside of the clinic setting. Over the past several decades, evidence has accumulated on two approaches for measuring out-of-clinic blood pressure: ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). Blood pressure measures on ABPM and HBPM each have a stronger association with CVD outcomes than clinic blood pressure. Controversy exists whether ABPM or HBPM is superior for estimating CVD risk, and under what circumstances these methods should be used in clinical practice for assessing out-of-clinic blood pressure. This review describes ABPM and HBPM procedures, the blood pressure phenotypic measures that can be ascertained, and the evidence that supports the use of each approach to measure out-of-clinic blood pressure. This review also describes barriers to the successful implementation of ABPM and HBPM in clinical practice, proposes core competencies for the conduct of these procedures, and highlights important areas for future research. PMID:26457954

  5. Characteristics of medicine-pediatrics practices: results from the national ambulatory medical care survey.

    PubMed

    Fortuna, Robert J; Ting, David Y; Kaelber, David C; Simon, Steven R

    2009-03-01

    Combined medicine-pediatrics (med-peds) training has existed for 40 years, yet little is known about national med-peds practices. A more comprehensive understanding of med-peds practices is important to inform medical students and guide evolving curricula and accreditation standards. The authors used data from the National Ambulatory Medical Care Survey from 2000 to 2006 to characterize the age distribution and types of visits seen by med-peds, internal medicine, pediatric, and family physicians. Forty-three percent of visits to med-peds physicians were from children < or = 18 years of age. Compared with family physicians, med-peds physicians saw a higher proportion of infants and toddlers < or = 2 years of age (21.0% versus 3.7%; P = .002) and children < or = 18 years of age (42.9% versus 15.5%; P = .002), but they treated fewer adults age 65 or older (13.8% versus 21.3%; P = .013). Compared with internists, med-peds physicians saw a greater percentage of visits from adults 19 to 64 years of age (75.8% versus 61.2%) and fewer visits from patients age 65 or older (24.2% versus 38.8%; P = .006). Med-peds physicians, like family physicians and pediatricians, most commonly treated patients for acute problems and reported high levels of continuity of care for patients-pediatric (93.6%) and adult (94.6%). Med-peds physicians care for a considerable proportion of pediatric patients while maintaining high levels of continuity of care for adult and pediatric patients. Within their practices, med-peds physicians treat a larger percentage of pediatric patients than do family physicians, but they see a smaller percentage of elderly patients.

  6. The impact of multiple chronic diseases on ambulatory care use; a population based study in Ontario, Canada.

    PubMed

    Muggah, Elizabeth; Graves, Erin; Bennett, Carol; Manuel, Douglas G

    2012-12-10

    The prevalence of multiple chronic diseases is increasing and is a common problem for primary health care providers. This study sought to determine the patient and health system burden of multiple chronic diseases among adults in Ontario, Canada, with a focus on the ambulatory health care system (outpatient primary health care and specialist services). This population-based study used linked health administrative data from Ontario, Canada. Individuals, aged 20 years or older, who had a valid health card, were included. Validated case definitions were used to identify persons with at least one of the following nine chronic diseases: diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end stage renal failure. Prevalence estimates for chronic diseases were calculated for April 1, 2009. Ambulatory physician billing records for the two-year period, April 1, 2008 to March 31, 2010, were used to identify the number of outpatient ambulatory care visits. In 2009, 26.3% of Ontarians had one chronic disease, 10.3% had two diseases, and 5.6% had three or more diseases. Annual mean primary health care use increased significantly with each additional chronic disease. Overall, there were twice as many patient visits to primary health care providers compared to specialists across all chronic disease counts. Among those with multiple diseases, primary health care visits increased with advancing age, while specialist care dropped off. While persons with three or more diseases accounted for a disproportionate share of primary health care visits, the largest number of visits were made by those with no or one chronic disease. The burden of care for persons with multiple chronic diseases is considerable and falls largely on the primary health care provider. However persons with no or one chronic disease are responsible for the largest number of ambulatory health care visits

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

    PubMed Central

    Chumbler, Neale R.; Yang, Kai; Saigal, Romesh; Abdollahi, Mohammad

    2016-01-01

    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. PMID:28462282

  8. Clinical value of ambulatory blood pressure: Is it time to recommend for all patients with hypertension?

    PubMed

    Solak, Yalcin; Kario, Kazuomi; Covic, Adrian; Bertelsen, Nathan; Afsar, Baris; Ozkok, Abdullah; Wiecek, Andrzej; Kanbay, Mehmet

    2016-02-01

    Hypertension is a very common disease, and office measurements of blood pressure are frequently inaccurate. Ambulatory Blood Pressure Monitoring (ABPM) offers a more accurate diagnosis, more detailed readings of average blood pressures, better blood pressure measurement during sleep, fewer false positives by detecting more white-coat hypertension, and fewer false negatives by detecting more masked hypertension. ABPM offers better management of clinical outcomes. For example, based on more accurate measurements of blood pressure variability, ABPM demonstrates that taking antihypertensive medication at night leads to better controlled nocturnal blood pressure, which translates into less end organ damage and fewer clinical complications of hypertension. For these reasons, albeit some shortcomings which were discussed, ABPM should be considered as a first-line tool for diagnosing and managing hypertension.

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

    PubMed

    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.

  10. Family Health Program and ambulatory care-sensitive conditions in Southern Brazil.

    PubMed

    Nedel, Fúlvio Borges; Facchini, Luiz Augusto; Martín-Mateo, Miguel; Vieira, Lúcia Azambuja Saraiva; Thumé, Elaine

    2008-12-01

    Ambulatory care-sensitive conditions (ACSC) are health problems managed by actions at the first level of care. The need for hospitalization by these causes is avoidable through an effective and proper primary health care. The objective of the study was to estimate ACSC among patients hospitalized by the Sistema Unico de Saúde (Brazilian Health System). Hospital-based cross-sectional study involving 1,200 inhabitants of Bagé (Southern Brazil) who were inpatients between September/2006 and January/2007. The patients answered a questionnaire applied by interviewers and were classified according to the model of attention utilized prior to hospitalization. ACSC were defined in a workshop promoted by the Ministry of Health. The variables analyzed included demographic and socioeconomic characteristics, health and health services utilized. Multivariate analysis was conducted by the Poisson model, according to a hierarchical conceptual framework, stratified by sex and model of care. ACSC accounted for 42.6% of the hospitalizations. The probability that the main diagnosis for hospitalization is considered an ACSC is greater among women, children under five years of age, individuals with less then five years of schooling, hospitalization in the year prior to the interview, emergency room consultation, and being an inpatient at the university hospital. Among women, ACSC are associated with age, educational level, length of time the health center has been in existence, living in an area covered by the Programa Saúde da Família (Family Health Program), use of this service, emergency room consultation during the month prior to the interview and hospital to which patient was admitted. For men, it was associated with age, have undergone another hospitalization in the year prior to the interview and hospital to which patient was admitted. Analysis of ACSC allows identifying groups with inadequate access to primary health care. Although we could not infer an effect on the risk of

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

    PubMed

    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.

  12. Identify, isolate, inform: Background and considerations for Ebola virus disease preparedness in U.S. ambulatory care settings.

    PubMed

    Chea, Nora; Perz, Joseph F; Srinivasan, Arjun; Laufer, Alison S; Pollack, Lori A

    2015-11-01

    Public health activities to identify and monitor persons at risk for Ebola virus disease in the United States include directing persons at risk to assessment facilities that are prepared to safely evaluate for Ebola virus disease. Although it is unlikely that a person with Ebola virus disease will unexpectedly present to a nonemergency ambulatory care facility, the Centers for Disease Control and Prevention have provided guidance for this setting that can be summarized as identify, isolate, and inform.

  13. Charging for Ambulatory Care in Military Health Care Facilities: An Evaluation and Analysis

    DTIC Science & Technology

    1983-04-25

    cross elasticities of demand for health care difficult or impossible to estimate. Health Status.- Kirsch et al𔃺 , DetwillerI I , Berki and...12, August 1974, 659-667. 15 Irving Leveson, "Access to Medical Care: The Queensbridge Experiment," Inquiry, 9, 1972, 61-67. 16 William C. Strattman...185-203. Leveson, Irving . "Access to Medical Care: The Queensbridge Experiment." 72 Inquiry, 9 (1972): 61-67. Maze, Rick. "Navy Leaders to Seek Better

  14. Recruiting primary care physicians to teach medical students in the ambulatory setting: a model of protected time, allocated money, and faculty development.

    PubMed

    Denton, G Dodd; Griffin, Ryan; Cazabon, Pedro; Monks, Shelly R; Deichmann, Richard

    2015-11-01

    Medical schools face barriers to recruiting physicians to teach in the ambulatory setting for many reasons, including time required to teach, loss of productivity when learners are present, and physicians' uncertainty about how to teach. In 2012, the primary care department of the University of Queensland-Ochsner Clinical School (UQ-OCS) implemented an innovative model for recruiting primary care physicians to teach students in their clinics. The model's three-pronged approach allows protected teaching time, allocates tuition money to reimburse physicians for teaching via educational value unit (EVU) tracking, and includes a faculty development program. In the first two years of EVU tracking (academic years 2012 and 2013), 5,530 EVUs were provided by 48 primary care faculty teaching 60 students at 11 sites. In academic year 2013, the first year in which tuition dollars were available to fund teaching by primary care faculty, over $120,000 in tuition money was transferred to the department to pay for EVUs. No faculty in 2012 or 2013 experienced a change in salary as a result of teaching activities. Faculty development workshops have been well attended. The general practice clerkship has been the top-rated third-year clerkship by students for the first three years of clinical rotations at the UQ-OCS. A qualitative study to describe the barriers to and solutions for recruiting physicians to teach students in ambulatory settings is planned. Other studies will evaluate the effectiveness of faculty development efforts and the impact of students' presence on patients' access to clinic appointments.

  15. Improving patient experience in a pediatric ambulatory clinic: a mixed method appraisal of service delivery.

    PubMed

    Soeteman, Marijn; Peters, Vera; Busari, Jamiu O

    2015-01-01

    In 2013, customer satisfaction surveys showed that patients were unhappy with the services provided at our ambulatory clinic. In response, we performed an appraisal of our services, which resulted in the development of a strategy to reduce waiting time and improve quality of service. Infrastructural changes to our clinic's waiting room, consultation rooms, and back offices were performed, and schedules were redesigned to reduce wait time to 10 minutes and increase consultation time to 20 minutes. Our objective was to identify if this would improve 1) accessibility to caregivers and 2) quality of service and available amenities. We conducted a multi-method survey using 1) a patient flow analysis to analyze the flow of service and understand the impact of our interventions on patient flow and 2) specially designed questionnaires to investigate patients' perceptions of our wait time and how to improve our services. The results showed that 79% of our respondents were called in to see a doctor within 20 minutes upon arrival. More patients (55%) felt that 10-20 minutes was an acceptable wait time. We also observed a perceived increase in satisfaction with wait time (94%). Finally, a large number of patients (97%) were satisfied with the quality of service and with the accessibility to caregivers (94%). The majority of our patients were satisfied with the accessibility to our ambulatory clinics and with the quality of services provided. The appraisal of our operational processes using a patient flow analysis also demonstrated how this strategy could effectively be applied to investigate and improve quality of service in patients.

  16. Ambulatory care for multidrug-resistant tuberculosis: lessons learned in Addis Ababa, Ethiopia

    PubMed Central

    Kumssa, H.; Tefera, M.; Tesfaye, A.; Klinkenberg, E.; Yimer, G.

    2014-01-01

    Setting: Ethiopia is one of the high multidrug-resistant tuberculosis (MDR-TB) burden countries. Efforts by the National TB Programme to control MDR-TB include expanding ambulatory care. Objective: To investigate the opportunities and challenges faced by treatment follow-up health centres (TFCs) when managing MDR-TB patients, with greater focus on recording, TB infection control (IC) and supervision practices. Methods: A facility-based cross-sectional study was conducted by reviewing the records of all MDR-TB cases in all 25 TFCs in Addis Ababa, Ethiopia. The TB focal point, pharmacy and laboratory heads were also interviewed. Result: A total of 221 MDR-TB patients were registered; 157 (71%) patients had been referred from one of the two treatment initiating centres. While some TFCs oversaw up to 41 patients, others had just one patient. The majority of the TFCs (n = 21, 84%) followed standardised TB IC procedures. Poor documentation of patient information was observed at all sites; for example, human immunodeficiency virus and current treatment status was not indicated for respectively 86 (38%) and 41 (18%) patients. Conclusion: The study revealed that infection prevention practices were largely adhered to. Documentation of patient-related information was a major challenge, and regular supervision of the TFCs should be emphasised. Record keeping is critical. PMID:26478512

  17. Modeling the impact of Medicare Advantage payment cuts on ambulatory care sensitive and elective hospitalizations.

    PubMed

    Nicholas, Lauren Hersch

    2011-10-01

    To assess relationships between changes in Medicare Advantage (MA) payment rates and Medicare beneficiary hospitalizations and to simulate the effects of scheduled payment cuts on ambulatory care sensitive (ACS) and elective hospitalization rates. State Inpatient Database discharge abstracts from Arizona, Florida, and New York merged with administrative Medicare enrollment and MA payment data. Retrospective, fixed effect regression analysis of the relationship between MA payment rates and rates of ACS and elective hospitalizations among Medicare beneficiaries in counties with at least 10,000 Medicare beneficiaries and 3 percent MA penetration from 1999 to 2005. MA payment rates were negatively related to rates of ACS admissions. Simulations suggest that payment cuts could be associated with higher rates of ACS admissions. No relationship between MA payments and rates of elective hospitalizations was found. Reductions in MA payment rates may result in a small increase in ACS admissions. Trends in ACS admissions among chronically ill Medicare beneficiaries should be tracked following MA payment cuts. © Health Research and Educational Trust.

  18. Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting.

    PubMed

    Porterfield, Amber; Engelbert, Kate; Coustasse, Alberto

    2014-01-01

    Electronic prescribing (e-prescribing) is an important part of the nation's push to enhance the safety and quality of the prescribing process. E-prescribing allows providers in the ambulatory care setting to send prescriptions electronically to the pharmacy and can be a stand-alone system or part of an integrated electronic health record system. The methodology for this study followed the basic principles of a systematic review. A total of 47 sources were referenced. Results of this research study suggest that e-prescribing reduces prescribing errors, increases efficiency, and helps to save on healthcare costs. Medication errors have been reduced to as little as a seventh of their previous level, and cost savings due to improved patient outcomes and decreased patient visits are estimated to be between $140 billion and $240 billion over 10 years for practices that implement e-prescribing. However, there have been significant barriers to implementation including cost, lack of provider support, patient privacy, system errors, and legal issues.

  19. Comparative evaluation of an ambulatory EEG platform vs. clinical gold standard.

    PubMed

    Jackson, Gregory; Radhu, Natasha; Sun, Yinming; Tallevi, Kevin; Ritvo, Paul; Daskalakis, Zafiris J; Grundlehner, Bernard; Penders, Julien; Cafazzo, Joseph A

    2013-01-01

    Electroencephalography (EEG) testing in clinical labs makes use of large amplifiers and complex software for data acquisition. While there are new ambulatory electroencephalogram (EEG) systems, few have been directly compared to a gold standard system. Here, an ultra-low power wireless EEG system designed by Imec is tested against the gold standard Neuroscan SynAmps2 EEG system, recording simultaneously from the same laboratory cap prepared with electrode gel. The data was analyzed using correlation analysis for both time domain and frequency domain data. The analysis indicated a high Pearson's correlation coefficient (mean=0.957, median=0.985) with high confidence (mean P=0.002) for 10-second sets of data transformed to the frequency domain. The time domain results had acceptable Pearson's coefficient (mean=0.580, median =0.706) with high confidence (mean P=0.008).

  20. New Clinical and Research Trends in Lower Extremity Management for Ambulatory Children with Cerebral Palsy

    PubMed Central

    Damiano, Diane L.; Alter, Katharine E.; Chambers, Henry

    2010-01-01

    Synopsis Cerebral palsy is the most prevalent physical disability in childhood and includes a group of disorders with varying manifestations and levels of capability in individuals given this diagnosis. This chapter will focus on current and future intervention strategies for improving mobility and participation over the lifespan for ambulatory children with cerebral palsy (CP). The provision and integration of physical therapy, medical and orthopedic surgery management focused primarily on the lower extremities will be discussed here. Some of the newer trends are: more intense and task-related exercise strategies, greater precision in tone identification and management, and a shift towards musculoskeletal surgery that focuses more on promoting dynamic bony alignment and less on releasing or lengthening tendons. Advances in basic and clinical science and technology development are changing existing paradigms and offering renewed hope for improved functioning for children with CP who are currently facing a lifelong disability with unique challenges at each stage in life. PMID:19643348

  1. Improving patient experience in a pediatric ambulatory clinic: a mixed method appraisal of service delivery

    PubMed Central

    Soeteman, Marijn; Peters, Vera; Busari, Jamiu O

    2015-01-01

    Objective In 2013, customer satisfaction surveys showed that patients were unhappy with the services provided at our ambulatory clinic. In response, we performed an appraisal of our services, which resulted in the development of a strategy to reduce waiting time and improve quality of service. Infrastructural changes to our clinic’s waiting room, consultation rooms, and back offices were performed, and schedules were redesigned to reduce wait time to 10 minutes and increase consultation time to 20 minutes. Our objective was to identify if this would improve 1) accessibility to caregivers and 2) quality of service and available amenities. Design We conducted a multi-method survey using 1) a patient flow analysis to analyze the flow of service and understand the impact of our interventions on patient flow and 2) specially designed questionnaires to investigate patients’ perceptions of our wait time and how to improve our services. Results The results showed that 79% of our respondents were called in to see a doctor within 20 minutes upon arrival. More patients (55%) felt that 10–20 minutes was an acceptable wait time. We also observed a perceived increase in satisfaction with wait time (94%). Finally, a large number of patients (97%) were satisfied with the quality of service and with the accessibility to caregivers (94%). Conclusion The majority of our patients were satisfied with the accessibility to our ambulatory clinics and with the quality of services provided. The appraisal of our operational processes using a patient flow analysis also demonstrated how this strategy could effectively be applied to investigate and improve quality of service in patients. PMID:25848303

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

    PubMed Central

    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

  3. Evaluation of Ambulatory Care Classification Systems for the Military Health Care System

    DTIC Science & Technology

    1990-12-31

    base and/or a large health care system, this manual tool was not tested. A system that appeared promising but was not available at the time of the...singular payment technique that could respond to the variety of conditions in these diverse settings. The primary savings gained from the use of DRGs are...frequently with the primary care and non-surgical specialties because of the nature of the CPT-4 manual . It contains more codes for surgical procedures

  4. Client satisfaction and unmet needs assessment: evaluation of an HIV ambulatory health care facility in Sydney, Australia.

    PubMed

    Chow, Maria Yui Kwan; Li, Mu; Quine, Susan

    2012-03-01

    A mixed-methods approach study was conducted at an ambulatory HIV health care facility in Sydney during 2007/2008. A quantitative self-administered structured questionnaire survey (phase 1) was conducted to assess client satisfaction levels, followed by qualitative semistructured interviews (phase 2) to investigate reasons for satisfaction/dissatisfaction and unmet needs. The mean overall satisfaction score of the 166 respondents in phase 1 was high (86 out of 100). Participants were most satisfied with the "knowledge" and "attitudes" of health care providers (HCP) and "maintenance of confidentiality." They were least satisfied with "waiting time before consultation." "Knowledge of HCP" and "rapport, care, and trust towards HCP" emerged as most important aspects of satisfaction. The broad range of HCP and services provided at one location was particularly appreciated. Health care service evaluation by assessing client satisfaction using mixed methods provided valuable insight into health care service quality. It can be applied to a broader range of health care services.

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

    PubMed

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

    2012-01-01

    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. To explore possibilities for public-private collaboration in the provision of ambulatory care at the primary level in the Mekong region, Vietnam. 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. 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. 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 quality assurance system, and strengthening

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

    PubMed Central

    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

  7. Characteristics, drug combinations and dosages of primary care patients with uncontrolled ambulatory blood pressure and high medication adherence.

    PubMed

    Grigoryan, Larissa; Pavlik, Valory N; Hyman, David J

    2013-01-01

    Most studies on the prevalence and determinants of resistant hypertension (RH) do not account for white coat hypertension, medication non-adherence, or use of suboptimal treatment dosages. We studied the characteristics, drug combinations, and dosages of patients on at least three antihypertensives of different classes who had uncontrolled blood pressure on 24-hour ambulatory blood pressure monitoring and high medication adherence measured by electronic monitoring. The data were collected as part of the baseline measures of a hypertension control trial. Of 140 monitored primary care patients, all with uncontrolled office blood pressure, 69 (49%) were on at least three antihypertensives of different classes. Of these 69, 15 (22%) were controlled on ambulatory blood pressure monitoring, 20 (29%) were uncontrolled and non-adherent, leaving only 34 (49%) adherent to their medications and having uncontrolled ambulatory hypertension (uncontrolled RH). Thirty-one (91%) of the 34 uncontrolled RH patients were prescribed a diuretic, of which 24 were on hydrochlorothiazide 25 mg. Less than half of the patients on angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or calcium channel blocker were prescribed maximal doses of these agents. Half of the RH can be attributed to white coat effect and poor medication adherence, and all of the remaining patients were on apparently suboptimal drug combinations and/or dosages. Primary care physicians need to be educated regarding the optimal treatment of RH. Copyright © 2013 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

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

    PubMed

    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

  9. Brand Name and Generic Proton Pump Inhibitor Prescriptions in the United States: Insights from the National Ambulatory Medical Care Survey (2006–2010)

    PubMed Central

    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

  10. Clinical value of ambulatory blood pressure in pediatric patients after renal transplantation.

    PubMed

    Krmar, Rafael T; Ferraris, Jorge R

    2017-08-25

    Hypertension is a highly prevalent co-morbidity in pediatric kidney transplant recipients. Undertreated hypertension is associated with cardiovascular complications and negatively impacts renal graft survival. Thus, the accurate measurement of blood pressure is of the utmost importance for the correct diagnosis and subsequent management of post-renal transplant hypertension. Data derived from the general population, and to a lesser extent from the pediatric population, indicates that ambulatory blood pressure monitoring (ABPM) is superior to blood pressure measurements taken in the clinical setting for the evaluation of true mean blood pressure, identification of patients requiring antihypertensive treatment, and in the prediction of cardiovascular outcome. This Educational Review will discuss the clinical value of ABPM in the identification of individual blood pressure phenotypes, i.e., normotension, new-onset hypertension, white-coat hypertension, masked hypertension, controlled blood pressure, and undertreated/uncontrolled hypertension in pediatric kidney transplant recipients. Finally, we examine the utility of performing repeated ABPM for treatment monitoring of post-renal transplant hypertension and on surrogate markers related to relevant clinical cardiovascular outcomes. Taken together, our review highlights the clinical value of the routine use of ABPM as a tool for identifying and monitoring hypertension in pediatric kidney transplant recipients.

  11. [The Integrated Psychological Treatment (IPT) program in an ambulatory psychiatric context: a clinical study].

    PubMed

    Zanello, Adriano; Merlo, Marco

    2004-01-01

    Among the actual rehabilitation programs offered to patients with schizophrenic disorders, the IPT (Integrated Psychological Treatment) is one paradigm which combines cognitive and psychosocial strategies. A solid body of evidence, derived from controlled studies, indicates that IPT improves cognitive and social functioning and reduces symptoms severity. Nevertheless, little is known about its efficacy in routine clinical conditions. In this article, the authors address this issue. Our clinical experience with IPT in an ambulatory psychiatric service is presented. The results show that only few patients find useful to participate to all IPT strategies. Patients who refuse or accept to be enrolled in this rehabilitation program share the same demographic, clinical., symptoms and cognitive characteristics. After two years, the outcome of these two groups is similar when we consider the rate of readmissions, the number of hospitalisations, the length of stay and the number of suicides. These observations suggest that IPT strategies in clinical routine are probably less efficient than in well controlled studies. They also raise the question to define an individualised rehabilitation program that fits particular patients' needs.

  12. Azilsartan in Patients With Mild to Moderate Hypertension Using Clinic and Ambulatory Blood Pressure Measurements.

    PubMed

    Perez, Alfonso; Cao, Charlie

    2017-01-01

    This was a phase 2, multicenter, randomized, parallel-group, double-blind dose-ranging study. Hypertensive adults (n=555) received one of five doses of azilsartan (AZL; 2.5, 5, 10, 20, 40 mg), olmesartan medoxomil (OLM) 20 mg, or placebo once daily. The primary endpoint was change in trough clinic diastolic blood pressure (DBP) at week 8. Compared with placebo, all AZL doses (except 2.5 mg) provided statistically and clinically significant reductions in DBP and systolic blood pressure (SBP) based on both clinic blood pressure (BP) and 24-hour ambulatory BP monitoring (ABPM). AZL 40 mg was statistically superior vs OLM. Clinic BP was associated with a pronounced placebo effect (-6 mm Hg), whereas this was negligible with ABPM (±0.5 mm Hg). Adverse event frequency was similar in the AZL and placebo groups. Based on these and other findings, subsequent trials investigated the commercial AZL medoxomil tablet at doses 20 to 80 mg/d using 24-hour ABPM. ©2016 Wiley Periodicals, Inc.

  13. Relationship between Ambulatory BP and Clinical Outcomes in Patients with Hypertensive CKD

    PubMed Central

    Rahman, Mahboob; Hu, Bo; Appel, Lawrence J.; Charleston, Jeanne; Contreras, Gabriel; Faulkner, Marquetta L.; Hiremath, Leena; Jamerson, Kenneth A.; Lea, Janice P.; Lipkowitz, Michael S.; Pogue, Velvie A.; Rostand, Stephen G.; Smogorzewski, Miroslaw J.; Wright, Jackson T.; Greene, Tom; Gassman, Jennifer; Wang, Xuelei; Phillips, Robert A.

    2012-01-01

    Summary Background and objectives Abnormal ambulatory BP (ABP) profiles are commonplace in CKD, yet the prognostic value of ABP for renal and cardiovascular outcomes is uncertain. This study assessed the relationship of baseline ABP profiles with CKD progression and subsequent cardiovascular outcomes to determine the prognostic value of ABP beyond that of clinic BP measurements. Design, setting, participants, & measurements Between 2002 and 2003, 617 African Americans with hypertensive CKD treated to a clinic BP goal of <130/80 mmHg were enrolled in this prospective, observational study. Participants were followed for a median of 5 years. Primary renal outcome was a composite of doubling of serum creatinine, ESRD, or death. The primary cardiovascular outcome was a composite of myocardial infarction, hospitalized congestive heart failure, stroke, revascularization procedures, cardiovascular death, and ESRD. Results Multivariable Cox proportional hazard analysis showed that higher 24-hour systolic BP (SBP), daytime, night-time, and clinic SBP were each associated with subsequent renal (hazard ratio, 1.17–1.28; P<0.001) and cardiovascular outcomes (hazard ratio, 1.22–1.32; P<0.001). After controlling for clinic SBP, ABP measures were predictive of renal outcomes in participants with clinic SBP <130 mmHg (P<0.05 for interaction). ABP predicted cardiovascular outcomes with no interaction based on clinic BP control. Conclusions ABP provides additional information beyond that of multiple clinic BP measures in predicting renal and cardiovascular outcomes in African Americans with hypertensive CKD. The primary utility of ABP in these CKD patients was to identify high-risk individuals among those patients with controlled clinic BP. PMID:22935847

  14. Thromboprophylaxis in ambulatory lung cancer treatment.

    PubMed

    Cavaliere, Loretta

    2013-02-01

    Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, are common problems experienced by patients with lung cancer that can impact treatment plans, prognoses, and survival. Patients with lung cancer are at greatest risk for development of VTE in the ambulatory care treatment setting. Literature does exist on VTE management for medical and surgical oncology inpatients, as well as clinical guidelines for inpatient prophylaxis; however, published evidence is lacking on outpatient risk and thromboprophylaxis in medical oncology outpatients, particularly patients with lung cancer. Because patients with lung cancer treated in the ambulatory setting have established risks for VTE, they may benefit from thromboprophylaxis. Clinical guidelines for outpatient thromboprophylaxis direct the clinical practice for thromboprophylaxis in lung cancer treatment. The purpose of the current article is to explore the VTE risks associated with ambulatory lung cancer treatment and to review the recommended guidelines for thromboprophylaxis to guide clinical decision making for patients with lung cancer.

  15. Underutilization of Aspirin Persists in US Ambulatory Care for the Secondary and Primary Prevention of Cardiovascular Disease

    PubMed Central

    Stafford, Randall S; Monti, Veronica; Ma, Jun

    2005-01-01

    Background Despite the proven benefits of aspirin therapy in the primary and secondary prevention of cardiovascular disease (CVD), utilization rates of aspirin remain suboptimal in relation to recommendations. We studied national trends of aspirin use among intermediate- to high-risk patients in the US ambulatory care settings and compared the priority given to aspirin versus statins for CVD risk reduction. We also examined patient and health care provider contributors to the underuse of aspirin. Methods and Findings We used the 1993–2003 US National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to estimate aspirin use by cardiovascular risk. Physician-noted cardiovascular diseases defined high risk. Intermediate risk was defined as having diabetes mellitus or multiple major risk factors. The proportion of patient visits in which aspirin was reported increased from 21.7% (95% confidence interval: 18.8%–24.6%) in 1993–1994 to 32.8% (25.2%–40.4%) in 2003 for the high-risk category, 3.5% (2.0%–5.0%) to 11.7% (7.8%–15.7%) for visits by patients diagnosed with diabetes, and 3.6% (2.6%–4.6%) to 16.3% (11.4%–21.2%) for those with multiple CVD risk factors. Beginning in 1997–1998, statins were prioritized over aspirin as prophylactic therapy for reducing CVD risk, and the gaps remained wide through 2003. In addition to elevated CVD risk, greater aspirin use was independently associated with advanced age, male gender, cardiologist care, and care in hospital outpatient departments. Conclusion Improvements in use of aspirin in US ambulatory care for reducing risks of CVD were at best modest during the period under study, particularly for secondary prevention, where the strongest evidence and most explicit guidelines exist. Aspirin is more underused than statins despite its more favorable cost-effectiveness. Aggressive and targeted interventions are needed to enhance provider and patient adherence to consensus guidelines

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

    PubMed

    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 A1C (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 < 0.01), a moderate effect representing a mean difference of 1.1% (95% CI = 0.88-1.27). The effects for systolic blood pressure and low-density lipoprotein cholesterol were between small and moderate (SMD = 0.31 and 0.32; P < 0.01). The heterogeneity was high for all outcomes (>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.

  17. Do racial/ethnic disparities exist in recommended migraine treatments in US ambulatory care?

    PubMed

    Charleston Iv, Larry; Burke, James Francis

    2017-01-01

    Background Racial disparities in migraine have been reported in the US. Migraine in African Americans (AA) is more frequent, more severe, more likely to become chronic and associated with more depression and lower quality of life compared to non-Hispanic Whites (NHW). It is possible that racial differences in prescribing practices contribute to these differences, but little is known about the quality of migraine prescribing patterns in the US or whether racial differences exist. Objective To determine if racial differences in quality of migraine medical prescription care exist. Methods We used data from the National Ambulatory Medical Care Survey to estimate differences in the use of migraine prophylactic and abortive medications by race. Quality of migraine care was defined using the American Academy of Neurology Headache Quality Measure Set (AAN-HQMS). Patients were assigned to one of four categories representing the overall quality of evidence for their abortive and prophylactic medications using the AAN-HQMS. We hypothesized that there would be suboptimal migraine treatment in minority populations. Racial comparisons were made using descriptive statistics after applying NAMCS survey weights. Results Two thousand, eight hundred and sixty visits were included in the study, representing approximately 50 million migraine visits in the US from 2006-2013. In all, 41.3% of AA, 40.8% of NHW, and 41.2% of Hispanic (HI) patients received no prophylactic treatments ( p = 0.99). A total of 18.8% of AA patients, 11.9% of NHW patients, and 6.9% of HI patients received exclusively Level A prophylaxis ( p = 0.30). A total of 47.1% of AA patients, 38.2% of NHW patients, and 36.3% of HI patients received no abortive treatments ( p = 0.23). In total, 15.3% of AA patients, 19.4% of NHW patients, and 17.7% of HI patients received any Level A abortives (i.e. triptans or Dihydroergotamine; DHE, p = 0.64). A total of 15.2% of all patients had a prescription for opiates

  18. Comparing patients who leave the ED prematurely, before vs after medical evaluation: a National Hospital Ambulatory Medical Care Survey analysis.

    PubMed

    Moe, Jessica; Belsky, Justin Brett

    2016-05-01

    Many patients leave the Emergency Department (ED) before beginning or completing medical evaluation. Some of these patients may be at higher medical risk depending on their timing of leaving the ED. To compare patient, hospital, and visit characteristics of patients who leave before completing medical care to patients who leave before ED evaluation. Retrospective cross-sectional analysis of ED visits using the 2009-2011 National Hospital Ambulatory Medical Care Survey. A total of 100962 ED visits were documented in the 2009-2011 National Hospital Ambulatory Medical Care Survey, representing a weighted count of 402211907 total ED visits. 2646 (2.62%) resulted in a disposition of left without completing medical care. Of these visits, 1792 (67.7%) left before being seen by a medical provider versus 854 (32.3%) who left after medical provider evaluation but before a final disposition. Patients who left after being assessed by a medical provider were older, had higher acuity visits, were more likely to have visited an ED without nursing triage, arrived more often by ambulance, and were more likely to have private insurance than to be self-paying or to have other payment arrangements (e.g. worker's compensation or charity/no charge). When comparing all patients who left the ED before completion of care, those who left after versus before medical provider evaluation differed in their patient, hospital, and visit characteristics and may represent a high risk patient group. Copyright © 2016 Elsevier Inc. All rights reserved.

  19. Initiation of treatment for incident diabetes: evidence from the electronic health records in an ambulatory care setting.

    PubMed

    Chung, Sukyung; Zhao, Beinan; Lauderdale, Diane; Linde, Randolph; Stafford, Randall; Palaniappan, Latha

    2015-02-01

    We examined patterns and predictors of initiation of treatment for incident diabetes in an ambulatory care setting in the US. Data were extracted from electronic health records (EHR) for active patients ≥ 35 years in a multispecialty, multiclinic ambulatory care organization with 1000 providers. New onset type 2 diabetes and subsequent treatment were identified using lab, diagnosis, medication prescription, and service use data. Time from the first evidence of diabetes until initial treatment, either medication or education/counseling, was examined using a Kaplan-Meier hazards curve. Potential predictors of initial treatment were examined using multinomial logistic models accounting for physician random effects. Of 2258 patients with incident diabetes, 55% received either medication or education/counseling (20% received both) during the first year. Of the treated patients, 68% received a treatment within the first four weeks, and 13% after initial 16 weeks. Strong positive predictors (P < 0.01) of combined treatment were younger age, higher fasting glucose at diagnosis, obesity, and visits with an endocrinologist. Among insured patients who have a primary care provider in a multispecialty health care system, incident diabetes is treated only half the time. Improved algorithms for identifying incident diabetes from the EHR and team approach for monitoring may help treatment initiation. Copyright © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

  20. Avoidable Antibiotic Exposure for Uncomplicated Skin and Soft Tissue Infections in the Ambulatory Care Setting

    PubMed Central

    Hurley, Hermione J.; Knepper, Bryan C.; Price, Connie S.; Mehler, Philip S.; Burman, William J.; Jenkins, Timothy C.

    2014-01-01

    Background Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotics. A detailed understanding of current prescribing practices is necessary to optimize antibiotic use for these conditions. Methods This was a retrospective cohort study of children and adults treated in the ambulatory care setting for uncomplicated cellulitis, wound infection, or cutaneous abscess between March 1, 2010 and February 28, 2011. We assessed the frequency of avoidable antibiotic exposure, defined as: use of antibiotics with broad gram-negative activity, combination antibiotic therapy, or treatment for 10 or more days. Total antibiotic-days prescribed for the cohort were compared to antibiotic-days in four hypothetical short-course (5 – 7 days), single-antibiotic treatment models consistent with national guidelines. Results 364 cases were included for analysis (155 cellulitis, 41 wound infection, and 168 abscess). Antibiotics active against methicillin-resistant Staphylococcus aureus were prescribed in 61% of cases of cellulitis. Of 139 cases of abscess where drainage was performed, antibiotics were prescribed in 80% for a median of 10 (interquartile range 7 – 10) days. Of 292 total cases where complete prescribing data were available, avoidable antibiotic exposure occurred in 46%. This included use of antibiotics with broad gram-negative activity in 4%, combination therapy in 12%, and treatment for 10 or more days in 42%. Use of the short-course, single-antibiotic treatment strategies would have reduced prescribed antibiotic-days by 19 – 55%. Conclusions Nearly half of uncomplicated skin infections involved avoidable antibiotic exposure. Antibiotic use could be reduced through treatment approaches utilizing short courses of a single antibiotic. PMID:24262724

  1. Nonresponse Bias in Estimates From the 2012 National Ambulatory Medical Care Survey.

    PubMed

    Hing, Esther; Shimizu, Iris M; Talwalkar, Anjali

    2016-02-01

    The National Ambulatory Medical Care Survey (NAMCS) is an annual, nationally representative sample survey of physicians and of visits to physicians. Two major changes were made to the 2012 NAMCS to support reliable state estimates. The sampling design changed from an area sample to a fivefold-larger list sample of physicians stratified by the nine U.S. Census Bureau divisions and 34 states. At the same time, the data collection mode changed from paper forms to laptop-assisted data collection and from physician or office staff abstraction of medical records to predominantly Census interviewer abstraction using automated Patient Record Forms (PRFs). This report presents an analysis of potential nonresponse bias in 2012 NAMCS estimates of physicians and visits to physicians. This analysis used two sets of physician-based estimates: one measuring the completion of the physician induction interview and another based on completing any PRF. Evaluation of visit response was measured by the percentage of expected PRFs completed. For each type of physician estimate, response was evaluated by (a) comparing percent distributions of respondents and nonrespondents by physician characteristics available for all in-scope sample physicians, (b) comparing response rates by physician characteristics with the national response rate, and (c) analyzing nonresponse bias after adjustments for nonresponse were applied in survey weights. For visit estimates, response was evaluated by (a) comparing the percent distributions of expected visits and completed visits, (b) comparing visit response rates by physician characteristics with the national visit response rate, and (c) analyzing visit-level nonresponse bias after adjustments for nonresponse were applied in visit survey weights. Finally, potential bias in the two physician-level estimates was computed by comparing them with those from an external survey.

  2. Changing relationship among clinic, home, and ambulatory blood pressure with increasing age.

    PubMed

    Stergiou, George S; Ntineri, Angeliki; Kollias, Anastasios; Destounis, Antonios; Nasothimiou, Efthimia; Roussias, Leonidas

    2015-07-01

    Studies in adults have shown similar levels of home (HBP) and daytime ambulatory blood pressure (dABP), which are lower than clinic blood pressure (CBP) measurements. This study investigated the impact of age on these differences. A total of 642 untreated children, adolescents, and adults referred to a hypertension clinic were evaluated with CBP, HBP, and dABP measurements within 4 weeks (mean age 38.6 ± 19.4 years; range 5-78 years; 61.1% males). In children, dABP was higher than both CBP and HBP. These differences were progressively eliminated with increasing age, and after the age of 30 years, dABP was similar to HBP, and both were lower than CBP. In subjects aged ≥60 years, dABP appeared to be lower than HBP. Age and hypertension appeared to be the main independent predictors of the differences among the three methods.These data suggest that the relationship between office and out-of-office blood pressure measurements is not the same across all age groups and should be taken into account in the evaluation of subjects with elevated blood pressure in clinical practice. Copyright © 2015 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

  3. Impact of Clinical Reminder Redesign on Learnability, Efficiency, Usability, and Workload for Ambulatory Clinic Nurses

    PubMed Central

    Saleem, Jason J.; Patterson, Emily S.; Militello, Laura; Anders, Shilo; Falciglia, Mercedes; Wissman, Jennifer A.; Roth, Emilie M.; Asch, Steven M.

    2007-01-01

    Objective Computerized clinical reminders (CRs) were designed to reduce clinicians’ reliance on their memory and to present evidence-based guidelines at point of care. However, the literature indicates that CR adoption and effectiveness has been variable. We examined the impact of four design modifications to CR software on learnability, efficiency, usability, and workload for intake nursing personnel in an outpatient clinic setting. These modifications were included in a redesign primarily to address barriers to effective CR use identified during a previous field study. Design In a simulation experiment, 16 nurses used prototypes of the current and redesigned system in a within-subject comparison for five simulated patient encounters. Prior to the experimental session, participants completed an exploration session, where “learnability” of the current and redesigned systems was assessed. Measurements Time, performance, and survey data were analyzed in conjunction with semi-structured debrief interview data. Results The redesign was found to significantly increase learnability for first-time users as measured by time to complete the first CR, efficiency as measured by task completion time for two of five patient scenarios, usability as determined by all three groupings of questions taken from a commonly used survey instrument, and two of six workload subscales of the NASA Task Load Index (TLX) survey: mental workload and frustration. Conclusion Modest design modifications to existing CR software positively impacted variables that likely would increase the willingness for first-time nursing personnel to adopt and consistently use CRs. PMID:17600106

  4. 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).

    PubMed

    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.

  5. A replicable and customizable approach to improve ambulatory care and research.

    PubMed

    Wasson, J H; Jette, A M; Johnson, D J; Mohr, J J; Nelson, E C

    1997-01-01

    Health care is a service industry. A fundamental attribute of many successful service industries is the "small replicable unit (SRU)." There are three essential elements of an SRU: (1) the smallest core unit of activity, (2) micromeasures designed to help manage the core activities, and (3) combinations of the activities and measures to match local customer needs. In this article, we describe a model for geriatric care based on "SRU thinking." We demonstrate how this approach places measurement of patient values, clinical improvement strategies, and research objectives into day-to-day health care delivery.

  6. Toward a highly accurate ambulatory system for clinical gait analysis via UWB radios.

    PubMed

    Shaban, Heba A; Abou el-Nasr, Mohamad; Buehrer, R Michael

    2010-03-01

    In this paper, we propose and investigate a low-cost and low-complexity wireless ambulatory human locomotion tracking system that provides a high ranging accuracy (intersensor distance) suitable for the assessment of clinical gait analysis using wearable ultra wideband (UWB) transceivers. The system design and transceiver performance are presented in additive-white-gaussian noise and realistic channels, using industry accepted channel models for body area networks. The proposed system is theoretically capable of providing a ranging accuracy of 0.11 cm error at distances equivalent to interarker distances, at an 18 dB SNR in realistic on-body UWB channels. Based on real measurements, it provides the target ranging accuracy at an SNR = 20 dB. The achievable accuracy is ten times better than the accuracy reported in the literature for the intermarker-distance measurement. This makes it suitable for use in clinical gait analysis, and for the characterization and assessment of unstable mobility diseases, such as Parkinson's disease.

  7. Clinical care costing method for the Clinical Care Classification System.

    PubMed

    Saba, Virginia K; Arnold, Jean M

    2004-01-01

    To provide a means for calculating the cost of nursing care using the Clinical Care Classification System (CCCS). Three CCCS indicators of care components, actions, and outcomes in conjunction with Clinical Care Pathways (CCPs). The cost of patient care is based on the type of action time multiplied by care components and nursing costs. The CCCM for the CCCS makes it possible to measure and cost out clinical practice. The CCCM may be used with CCPs in the electronic patient medical record. The CCPs make it easy to track the clinical nursing care across time, settings, population groups, and geographical locations. Collected data may be used many times, allowing for improved documentation, analysis, and costing out of care.

  8. [The state of quality management implementation in ambulatory care nursing and inpatient nursing].

    PubMed

    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

  9. Changes in uncompensated pediatric ambulatory care visits for uninsured children among safety net providers after implementing a health insurance program for children of low-income families.

    PubMed

    Cousineau, Michael R; Farias, Albert J

    2009-01-01

    The role of the safety net has been debated in various proposals for healthcare reform in the United States. Yet little is known about how health coverage expansion affects the use of safety net services. This study uses data from Los Angeles County to analyze how the expansion of health insurance for low-income uninsured children has affected their utilization of ambulatory care services in safety net hospitals and health centers. In the Los Angeles Healthy Kids program, 40 000 mostly immigrant children ineligible for State Children's Health Insurance Program or Medicaid, were enrolled in a new insurance program called Healthy Kids. Coverage expansion was associated with a decrease in the utilization of pediatric services in two county-funded programs for the uninsured: directly operated healthcare services and private contracted programs. Thus, coverage expansion may have saved more than $37 million in compensated care for children. For public hospitals and other safety net clinics, these data and previous studies suggest that insurance not only improves access but also reconfigures where people get care. It also helps reduce uncompensated care and provides new avenues to support and stabilize the healthcare safety net. These data suggest that a state or jointly funded insurance expansion will help offset the growing burden of uncompensated care among safety net providers while improving utilization and health status among children. Universal coverage programs are not only good for children but also help stabilize the fragile healthcare safety net by reducing the demand for uncompensated care at county facilities.

  10. A Break-Even Analysis of Optimum Faculty Assignment for Ambulatory Primary Care Training.

    ERIC Educational Resources Information Center

    Xakellis, George C.; And Others

    1996-01-01

    A computer simulation was developed to estimate the number of medical residents one or two faculty teachers could supervise in a university-based primary medical care teaching clinic. With no non-teaching tasks, it was shown that two teachers could supervise 11 residents, while one teacher was able to supervise only three residents under similar…

  11. Systematic Review of Ambulatory Transitional Care Management (TCM) Visits on Hospital 30-Day Readmission Rates.

    PubMed

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

    To reduce readmission rates and prevent adverse outcomes after discharge, hospitals have begun implementing "transitional care" initiatives. This systematic review identifies research on the particular set of services now reimbursable by Medicare (transitional care management [TCM]) and evaluates the studies for program effectiveness. Results of 3 databases were screened for peer-reviewed journal articles published between January 2004 and 2015 that report on readmissions of adults in the US health care system under the Medicare TCM bundle. ClinicalTrials.gov was queried for funded studies. Of 969 identified studies, 77 met inclusion criteria for relevance to transitional care and appropriateness of population and setting. Of these, only 3 articles incorporated all required elements for TCM service. Although 2 were program improvement designs and none were randomized controlled studies, each report reduced readmission rates. Evidence for TCM effectiveness is limited. Additional study of TCM implementation and programmatic support for TCM is warranted.

  12. Disposition of emergency department patients with psychiatric comorbidity: results from the 2004 National Hospital Ambulatory Medical Care Survey

    PubMed Central

    Kunen, S; Prejean, C; Gladney, B; Harper, D; Mandry, C V

    2006-01-01

    Background Few emergency department (ED) studies have examined how psychiatric comorbidity relates to hospitalisation decisions. Methods We assessed the relationship of psychiatric comorbidity to hospitalisation decisions among ED patients in the 2004 National Hospital Ambulatory Medical Care Survey. Results Patients with psychiatric comorbidity were five times more likely to be hospitalised than patients with a single psychiatric diagnosis. The most frequent psychiatric comorbidities involved substance use disorders (SUDs). Conclusions Psychiatric disorders are underdiagnosed among ED patients. We believe that this underdiagnosis may be partly responsible for the high hospitalisation rates of ED patients with SUDs PMID:16549572

  13. How many clinic BP readings are needed to predict cardiovascular events as accurately as ambulatory BP monitoring?

    PubMed

    Eguchi, K; Hoshide, S; Shimada, K; Kario, K

    2014-12-01

    We tested the hypothesis that multiple clinic blood pressure (BP) readings over an extended baseline period would be as predictive as ambulatory BP (ABP) for cardiovascular disease (CVD). Clinic and ABP monitoring were performed in 457 hypertensive patients at baseline. Clinic BP was measured monthly and the means of the first 3, 5 and 10 clinic BP readings were taken as the multiple clinic BP readings. The subjects were followed up, and stroke, HARD CVD, and ALL CVD events were determined as outcomes. In multivariate Cox regression analyses, ambulatory systolic BP (SBP) best predicted three outcomes independently of baseline and multiple clinic SBP readings. The mean of 10 clinic SBP readings predicted stroke (hazards ratio (HR)=1.39, 95% confidence interval (CI)=1.02-1.90, P=0.04) and ALL CVD (HR=1.41, 95% CI=1.13-1.74, P=0.002) independently of baseline clinic SBP. Clinic SBPs by three and five readings were not associated with any CVD events, except that clinic SBP by three readings was associated with ALL CVD (P=0.015). Besides ABP values, the mean of the first 10 clinic SBP values was a significant predictor of stroke and ALL CVD events. It is important to take more than several clinic BP readings early after the baseline period for the risk stratification of future CVD events.

  14. German Ambulatory Care Physicians' Perspectives on Continuing Medical Education--A National Survey

    ERIC Educational Resources Information Center

    Kempkens, Daniela; Dieterle, Wilfried E.; Butzlaff, Martin; Wilson, Andrew; Bocken, Jan; Rieger, Monika A.; Wilm, Stefan; Vollmar, Horst C.

    2009-01-01

    Introduction: This survey aimed to investigate German ambulatory physicians' opinions about mandatory continuing medical education (CME) and CME resources shortly before the introduction of mandatory CME in 2004. Methods: A structured national telephone survey of general practitioners and specialists was conducted. Main outcome measures were…

  15. Ambulatory Care in Medical Residency: Integration of Private Practitioner's Office with Traditional Sites.

    ERIC Educational Resources Information Center

    Bane, Susan; Criscione, Teri

    1983-01-01

    An Albany Medical College program utilizes private internists' offices as sites for resident ambulatory education. The private practitioner is perceived as an excellent teacher and role model who provides a positive effect on the long-term career goals of residents. (MLW)

  16. "Attention on the flight deck": what ambulatory care providers can learn from pilots about complex coordinated actions.

    PubMed

    Frankel, Richard M; Saleem, Jason J

    2013-12-01

    Technical and interpersonal challenges of using electronic health records (EHRs) in ambulatory care persist. We use cockpit communication as an example of highly coordinated complex activity during flight and compare it with providers' communication when computers are used in the exam room. Maximum variation sampling was used to identify two videotapes from a parent study of primary care physicians' exam room computer demonstrating the greatest variation. We then produced and analyzed visualizations of the time providers spent looking at the computer and looking at the patient. Unlike the cockpit which is engineered to optimize joint attention on complex coordinated activities, we found polar extremes in the use of joint focus of attention to manage the medical encounter. We conclude that there is a great deal of room for improving the balance of interpersonal and technical attention that occurs in routine ambulatory visits in which computers are present in the exam room. Using well-known aviation practices can help primary care providers become more aware of the opportunities and challenges for enhancing the physician patient relationship in an era of exam room computing. Published by Elsevier Ireland Ltd.

  17. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring.

    PubMed

    de la Sierra, Alejandro; Segura, Julián; Banegas, José R; Gorostidi, Manuel; de la Cruz, Juan J; Armario, Pedro; Oliveras, Anna; Ruilope, Luis M

    2011-05-01

    We aimed to estimate the prevalence of resistant hypertension through both office and ambulatory blood pressure monitoring in a large cohort of treated hypertensive patients from the Spanish Ambulatory Blood Pressure Monitoring Registry. In addition, we also compared clinical features of patients with true or white-coat-resistant hypertension. In December 2009, we identified 68 045 treated patients with complete information for this analysis. Among them, 8295 (12.2% of the database) had resistant hypertension (office blood pressure ≥140 and/or 90 mm Hg while being treated with ≥3 antihypertensive drugs, 1 of them being a diuretic). After ambulatory blood pressure monitoring, 62.5% of patients were classified as true resistant hypertensives, the remaining 37.5% having white-coat resistance. The former group was younger, more frequently men, with a longer duration of hypertension and a worse cardiovascular risk profile. The group included larger proportions of smokers, diabetics, target organ damage (including left ventricular hypertrophy, impaired renal function, and microalbuminuria), and documented cardiovascular disease. Moreover, true resistant hypertensives exhibited in a greater proportion a riser pattern (22% versus 18%; P<0.001). In conclusion, this study first reports the prevalence of resistant hypertension in a large cohort of patients in usual daily practice. Resistant hypertension is present in 12% of the treated hypertensive population, but among them more than one third have normal ambulatory blood pressure. A worse risk profile is associated with true resistant hypertension, but this association is weak, thus making it necessary to assess ambulatory blood pressure monitoring for a correct diagnosis and management.

  18. Clinical characteristics of resistant hypertension evaluated by ambulatory blood pressure monitoring.

    PubMed

    Kansui, Yasuo; Matsumura, Kiyoshi; Kida, Haruko; Sakata, Satoko; Ohtsubo, Toshio; Ibaraki, Ai; Kitazono, Takanari

    2014-01-01

    Strict control of blood pressure is important to prevent cardiovascular disease, although it is sometimes difficult to decrease blood pressure to target levels. The aim of this study was to investigate the clinical characteristics of resistant hypertension evaluated by ambulatory blood pressure monitoring. One hundred in-hospital patients, whose 24-hour average blood pressure was higher than 130/80 mmHg even after treatment with more than three antihypertensive drugs, were included in the present analysis. Circadian variation of blood pressure was evaluated by nocturnal fall in systolic blood pressure. Average blood pressures of all patients were high in both daytime and nighttime, 150.0/82.9 and 143.8/78.2 mmHg, respectively. Twenty patients had been treated with hemodialysis or peritoneal dialysis. In 63 patients out of the other 80 patients (79%), estimated glomerular filtration rate (eGFR) was also decreased (<60 mL/min/1.73 m²). The patients classified into dipper, non-dipper, riser and extreme-dipper were 20%, 43%, 34% and 3%, respectively. In addition, in 17 patients whose eGFR was preserved, 12 patients showed a non-dipper or riser pattern, suggesting that it was difficult to account for this altered circadian blood pressure variation only by renal dysfunction. These results show that a large number of the patients with resistant hypertension suffered from renal dysfunction, although it was difficult to explain altered circadian blood pressure variation based on renal dysfunction alone.

  19. [Ambulatory blood pressure monitoring (CABPM): clinical characteristics of 31,530 patients].

    PubMed

    Sierra, Cristina; De la Sierra, Alejandro; Sobrino, Javier; Segura, Julián; Banegas, José Ramón; Gorostidi, Manuel; Ruilope, Luis Miguel

    2007-06-02

    Ambulatory blood pressure monitoring (ABPM) is a useful diagnostic and therapeutic tool in hypertensive patients. This study reports the clinical characteristics of 31,530 patients included in the Spanish Registry of ABPM. A total number of 767 investigators recruited patients with suspected or confirmed hypertension to whom an ABPM was indicated with a validated device and included them in the study. Mean blood pressures from daytime, nighttime, and the whole 24-hour period were all measured. Circadian patterns were defined depending on nocturnal systolic blood pressure fall: extreme dipper (> 20%), dipper (10%-20%), non-dipper (< 10%) and riser (nocturnal blood pressure increase). 24-hour, daytime, and nighttime blood pressure values were lower than those obtained at the office. Twenty percent of patients exhibited elevated office blood pressure with normal values on ABPM ( hypertensives or false resistant) whereas 9% showed increased values on ABPM, but normal at the office (masked hypertension). The non-dipper or riser circadian patterns were present in more than half of the patients (40.2% and 13.4%, respectively) and were associated with an increased cardiovascular risk. Almost one third of hypertensive patients exhibit blood pressure values that are not concordant between office and ABPM. More than a half of patients, especially those at higher risk, present a circadian pattern with an inadequate nocturnal blood pressure fall.

  20. Development and Implementation of an Ambulatory Integrated Care Pathway for Major Depressive Disorder and Alcohol Dependence.

    PubMed

    Awan, Saima; Samokhvalov, Andriy V; Aleem, Nadia; Hendershot, Christian S; Irving, Julie Anne; Kalvik, Anne; Lefebvre, Lisa; Le Foll, Bernard; Quilty, Lena; Voore, Peter

    2015-12-01

    Integrated care pathways (ICPs) provide an approach for delivering evidence-based treatment in a hospital setting. This column describes the development and pilot implementation in a clinical setting of an ICP for patients with concurrent major depressive disorder and alcohol dependence at the Centre for Addiction and Mental Health (CAMH), an academic tertiary care hospital, in Toronto, Canada. The ICP methodology includes evidence reviews, knowledge translation, process reengineering, and change management. Pilot results indicate high patient satisfaction, evidence of symptom improvement, and excellent retention.

  1. Factors Associated with Hospitalisations for Ambulatory Care-Sensitive Conditions among Persons with an Intellectual Disability--A Publicly Insured Population Perspective

    ERIC Educational Resources Information Center

    Balogh, R. S.; Ouellette-Kuntz, H.; Brownell, M.; Colantonio, A.

    2013-01-01

    Background: Hospitalisations for ambulatory care-sensitive (ACS) conditions are used as an indicator of access to, and the quality of, primary care. The objective was to identify factors associated with hospitalisations for ACS conditions among adults with an intellectual disability (ID) in the context of a publicly insured healthcare system.…

  2. Factors Associated with Hospitalisations for Ambulatory Care-Sensitive Conditions among Persons with an Intellectual Disability--A Publicly Insured Population Perspective

    ERIC Educational Resources Information Center

    Balogh, R. S.; Ouellette-Kuntz, H.; Brownell, M.; Colantonio, A.

    2013-01-01

    Background: Hospitalisations for ambulatory care-sensitive (ACS) conditions are used as an indicator of access to, and the quality of, primary care. The objective was to identify factors associated with hospitalisations for ACS conditions among adults with an intellectual disability (ID) in the context of a publicly insured healthcare system.…

  3. Home versus ambulatory blood pressure monitoring in the diagnosis of clinic resistant and true resistant hypertension.

    PubMed

    Nasothimiou, E G; Tzamouranis, D; Roussias, L G; Stergiou, G S

    2012-12-01

    Ambulatory blood pressure (ABP) monitoring is recommended as a standard method for the evaluation of resistant hypertension (RH). This study assessed the diagnostic value of home blood pressure (HBP) monitoring in RH. Subjects on stable treatment with ≥3 antihypertensive drugs were included. Clinic RH (CRH) was defined as elevated clinic blood pressure and true RH (TRH) as elevated ABP. The diagnosis of CRH was verified by ABP and HBP monitoring. The diagnostic value of HBP was assessed by taking ABP as reference method. Threshold for hypertension diagnosis was ≥135/85 mm Hg (systolic and/or diastolic) for HBP and awake ABP and ≥140/90 mm Hg for clinic blood pressure. Among 73 subjects on ≥3 antihypertensive drugs, 44 (60%) had CRH and 40 (55%) TRH. There was agreement between ABP and HBP in diagnosing CRH in 82% of the cases (26 subjects (59%) with CRH and 10 (23%) without CRH; kappa 0.59). Regarding the diagnosis of TRH, there was agreement between ABP and HBP in 74% of the cases (36 subjects (49%) with TRH and 18 (25%) without TRH; kappa 0.46). The sensitivity, specificity, and positive and negative predictive values of HBP in detecting CRH were 93%, 63%, and 81% and 83%, respectively, and TRH were 90%, 55%, and 71%, and 82%, respectively (ABP taken as reference method). These data suggest that HBP is a reliable alternative to ABP in the evaluation of RH. These methods are necessary in both uncontrolled and controlled subjects on triple therapy to detect the white coat phenomenon and also masked RH.

  4. Anaesthesia for ambulatory paediatric surgery: common techniques and complications.

    PubMed

    Imarengiaye, C O; Osifo, D; Tudjegbe, S; Evbuomwan, I

    2009-01-01

    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 benchmark. This was a cross-sectional study of children who were presented for ambulatory surgical care in the University of Benin Teaching Hospital. A standardized questionnaire was employed to record the age, gender, indication for surgery, type of anaesthesia, timelines for the surgery and associated complications. A total of 93 patients had surgical procedures on ambulatory basis. The mean age of the patients was 4.1(4.0) yr and duration of surgical procedure 31.3(12.1) min. The male to female ratio was 3:1, and herniotomy was the most frequent procedure on ambulatory paediatric surgical care 60 (64.5%). The common anaesthetic techniques employed in the paediatric ambulatory setting were spontaneous respiration with face mask 40 (43%), Inhalation technique with tracheal intubations 31 (33.3%), general anaesthesia with relaxant technique five (5.4%), local infiltration with or without sedation eight (8.6%), GA plus caudal block eight(8.6%), and subarachnoid block one(1.1%). The indicators of quality care were unanticipated admission (5.4%), repeat hospital visit (4.3%), readmission (2.2%) and delayed discharge (21.5%). The practices of paediatric surgery on ambulatory services are feasible in our setting. The observable complications are within acceptable limits. The timelines in the scheduling and discharge appear not to be optimal for an effective ambulatory service.

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

    PubMed

    Busato, André; Matter, Pius; Künzi, Beat; Goodman, David C

    2010-11-23

    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. 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. 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, gynecology, pediatrics and for psychiatrists whereas

  6. [Task delegation scenarios at national and regional levels of the French ambulatory care sector].

    PubMed

    Lévy, Danièle; Pavot, Jeanne; Doan, Bui Dang Ha

    2009-01-01

    The French sector of ambulatory care is characterized by two features: (i) health care providers are mostly independent practitioners paid on a fee-for-service basis; (ii) a large consensus is observed as concerns the shortage of health workers, particularly physicians and nurses. In such a context, if a task delegation programme is envisaged, attention should be paid, not only to the competencies of task receivers, but equally to the reluctance of health workforce. Given the current doctor shortage, it is probable that the reluctance of physicians is not vigorous. But on the side of task receivers (nurses, physiotherapists, other auxiliary workers...) reluctance should be taken into account. Shortage of nurses and physiotherapists (and consequently their growing workload) lowers their acceptance level (i.e., the proportion accepting task delegation) and reduces the time each accepting worker can devote to the activities delegated by physicians. The model shows that, in the current situation, French physicians can only expect a small reduction of their workload i they undertake to transfer to nurses some parts of their activities. When physician working time is not excessively lengthy, the overall reduction would be between 0.7% and 3.1%. When doctors have to work harder (when their shortage is acute), paradoxically, the reduction is lower, between 0.5% and 2.3%. The fact is easily understood as the stock of task receivers (the nurses) remains unchanged, but the volume of worked hours becomes larger. Other things being equal, the model shows that French southern physicians may take more profit from a task delegation programme than their counterparts practising in the northern areas of the country. As in the southern areas, the nurse/physician ratio is higher, the potential task receivers are in higher numbers and the volume of the tasks transferred may be much broader than in the northern areas. The paradox is that the workload of northern physicians is heavier

  7. Off-Label Prescribing for Children with Migraines in U.S. Ambulatory Care Settings.

    PubMed

    Lai, L Leanne; Koh, Leroy; Ho, Jane Ai-Chen; Ting, Alexander; Obi, Augustine

    2017-03-01

    Migraines, Which Affect About 10% Of School-Age Children In The United States, Can Significantly Impair Quality Of Life. Despite Potential Disability, Many Children Do Not Receive Treatment Or Prophylaxis, Since Medications Specifically Approved For Children Are Significantly Less Than For Adults. There Is Also Controversy Surrounding The Apparent Widespread Practice Of Prescribing Off-Label Medications For Children With Migraines. However, Little Research Has Been Done To Identify Physician-Prescribing Patterns Of Migraine Medication For Children. To Investigate The Prevalence And Pattern Of Off-Label Prescribing For Children With Migraines. A Secondary Data Analysis Was Conducted Using The Pooled National Ambulatory Medical Care Survey (Namcs) 2011 And 2012. Patients Aged 17 Years Or Younger With A Migraine Diagnosis Were Included. A Series Of Weighted Descriptive Analyses Were Used To Estimate The Prevalence Of Migraine Drugs Prescribed During Pediatric Office Visits. A Weighted Logistic Regression Was Constructed To Compare The Prescribing Patterns Between Off-Label And Fda-Approved Medications. Analyses Used Sas 9.4 Methodology And Incorporated Sample Weights To Adjust For The Complex Sampling Design Employed By Namcs. Of The 12.9 Million Outpatient Visits With A Migraine Diagnosis That Took Place Between 2010 And 2012, 1.2 Million Were Pediatric Visits. Females Accounted For Nearly Twice The Number Of Migraine Visits Than Males (66% Vs. 34%). Children Aged 12-17 Years Accounted For The Highest Frequency Of Visits (84%), Compared With Those Aged Under 12 Years (16%). 66.7% Of These Pediatric Patients Received At Least 1 Migraine Drug. Of These, Off-Label Medications Were Prescribed 1.5 Times More Than Fda-Approved Medications For Children (60.34% Vs. 39.65%). The Results Of Logistic Regression Showed A Significant Likelihood Of Prescribing Off-Label Medications Based On Physician Specialty, Patient Race, And Reason For Visit. Neurologists (Or = 0.028, P < 0

  8. Patterns of ambulatory medical care utilization in elderly patients with special reference to chronic diseases and multimorbidity - Results from a claims data based observational study in Germany

    PubMed Central

    2011-01-01

    Background In order to estimate the future demands for health services, the analysis of current utilization patterns of the elderly is crucial. The aim of this study is to analyze ambulatory medical care utilization by elderly patients in relation to age, gender, number of chronic conditions, patterns of multimorbidity, and nursing dependency in Germany. Methods Claims data of the year 2004 from 123,224 patients aged 65 years and over which are members of one nationwide operating statutory insurance company in Germany were studied. Multimorbidity was defined as the presence of 3 or more chronic conditions of a list of 46 most prevalent chronic conditions based on ICD 10 diagnoses. Utilization was analyzed by the number of contacts with practices of physicians working in the ambulatory medical care sector and by the number of different physicians contacted for every single chronic condition and their most frequent triadic combinations. Main statistical analyses were multidimensional frequency counts with standard deviations and confidence intervals, and multivariable linear regression analyses. Results Multimorbid patients had more than twice as many contacts per year with physicians than those without multimorbidity (36 vs. 16). These contact frequencies were associated with visits to 5.7 different physicians per year in case of multimorbidity vs. 3.5 when multimorbidity was not present. The number of contacts and of physicians contacted increased steadily with the number of chronic conditions. The number of contacts varied between 35 and 54 per year and the number of contacted physicians varied between 5 to 7, depending on the presence of individual chronic diseases and/or their triadic combinations. The influence of gender or age on utilization was small and clinically almost irrelevant. The most important factor influencing physician contact was the presence of nursing dependency due to disability. Conclusion In absolute terms, we found a very high rate of

  9. Determining Primary Care Physician Information Needs to Inform Ambulatory Visit Note Display

    PubMed Central

    Clarke, M.A.; Steege, L.M.; Moore, J.L.; Koopman, R.J.; Belden, J.L.; Kim, M.S.

    2014-01-01

    Summary Background With the increase in the adoption of electronic health records (EHR) across the US, primary care physicians are experiencing information overload. The purpose of this pilot study was to determine the information needs of primary care physicians (PCPs) as they review clinic visit notes to inform EHR display. Method Data collection was conducted with 15 primary care physicians during semi-structured interviews, including a third party observer to control bias. Physicians reviewed major sections of an artificial but typical acute and chronic care visit note to identify the note sections that were relevant to their information needs. Statistical methods used were McNemar-Mosteller’s and Cochran Q. Results Physicians identified History of Present Illness (HPI), Assessment, and Plan (A&P) as the most important sections of a visit note. In contrast, they largely judged the Review of Systems (ROS) to be superfluous. There was also a statistical difference in physicians’ highlighting among all seven major note sections in acute (p = 0.00) and chronic (p = 0.00) care visit notes. Conclusion A&P and HPI sections were most frequently identified as important which suggests that physicians may have to identify a few key sections out of a long, unnecessarily verbose visit note. ROS is viewed by doctors as mostly “not needed,” but can have relevant information. The ROS can contain information needed for patient care when other sections of the Visit note, such as the HPI, lack the relevant information. Future studies should include producing a display that provides only relevant information to increase physician efficiency at the point of care. Also, research on moving A&P to the top of visit notes instead of having A&P at the bottom of the page is needed, since those are usually the first sections physicians refer to and reviewing from top to bottom may cause cognitive load. PMID:24734131

  10. A Physician's Practice Profile: Application for a Teaching Hospital Ambulatory Care Setting

    PubMed Central

    Retchin, Sheldon M.; Blish, Christine S.

    1984-01-01

    A computer generated report (Practice Profile) summarizing epidemiologic, demographic and utilization data from a general internal medicine practice, was developed and implemented in a teaching hospital setting. Using a computerized medical record system, the Profile displays individual and group practice data. It is used for enhancing the physicians' understanding of their ambulatory practices and for raising important quality assurance issues. The Practice Profile is also used for improving educational activities in the residency program and for stimulating research opportunities within the practice.

  11. Prevalence of Torture Survivors Among Foreign-Born Patients Presenting to an Urban Ambulatory Care Practice

    PubMed Central

    Crosby, Sondra S; Norredam, Marie; Paasche-Orlow, Michael K; Piwowarczyk, Linda; Heeren, Tim; Grodin, Michael A

    2006-01-01

    BACKGROUND The prevalence of torture among foreign-born patients presenting to urban medical clinics is not well documented. OBJECTIVE To determine the prevalence of torture among foreign-born patients presenting to an urban primary care practice. DESIGN A survey of foreign-born patients. PATIENTS Foreign-born patients, age ≥18, presenting to the Primary Care Clinic at Boston Medical Center. MEASUREMENTS Self-reported history of torture as defined by the UN, and history of prior disclosure of torture. RESULTS Of the 308 eligible patients, 88 (29%) declined participation, and 78 (25%) were not included owing to lack of a translator. Par ticipants had a mean age of 47 years (range 19 to 76), were mostly female (82/142, 58%), had been in the United States for an average of 14 years (range 1 month to 53 years), and came from 35 countries. Fully, 11% (16/142, 95 percent confidence interval 7% to 18%) of participants reported a history of torture that was consistent with the UN definition of torture. Thirty-nine percent (9/23) of patients reported that their health care provider asked them about torture. While most patients (15/23, 67%) reported discussing their experience of torture with someone in the United States, 8 of 23 (33%) reported that this survey was their first disclosure to anyone in the United States. CONCLUSION Among foreign-born patients presenting to an urban primary care center, approximately 1 in 9 met the definition established by the UN Convention Against Torture. As survivors of torture may have significant psychological and physical sequelae, these data underscore the necessity for primary care physicians to screen for a torture history among foreign-born patients. PMID:16808779

  12. Prevalence of torture survivors among foreign-born patients presenting to an urban ambulatory care practice.

    PubMed

    Crosby, Sondra S; Norredam, Marie; Paasche-Orlow, Michael K; Piwowarczyk, Linda; Heeren, Tim; Grodin, Michael A

    2006-07-01

    The prevalence of torture among foreign-born patients presenting to urban medical clinics is not well documented. To determine the prevalence of torture among foreign-born patients presenting to an urban primary care practice. A survey of foreign-born patients. Foreign-born patients, age > or = 18, presenting to the Primary Care Clinic at Boston Medical Center. Self-reported history of torture as defined by the UN, and history of prior disclosure of torture. Of the 308 eligible patients, 88 (29%) declined participation, and 78 (25%) were not included owing to lack of a translator. Participants had a mean age of 47 years (range 19 to 76), were mostly female (82/142, 58%), had been in the United States for an average of 14 years (range 1 month to 53 years), and came from 35 countries. Fully, 11% (16/142, 95 percent confidence interval 7% to 18%) of participants reported a history of torture that was consistent with the UN definition of torture. Thirty-nine percent (9/23) of patients reported that their health care provider asked them about torture. While most patients (15/23, 67%) reported discussing their experience of torture with someone in the United States, 8 of 23 (33%) reported that this survey was their first disclosure to anyone in the United States. Among foreign-born patients presenting to an urban primary care center, approximately 1 in 9 met the definition established by the UN Convention Against Torture. As survivors of torture may have significant psychological and physical sequelae, these data underscore the necessity for primary care physicians to screen for a torture history among foreign-born patients.

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

    PubMed

    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.

  14. Patient Education: A Better Way to Achieve Compliance in the Ambulatory Care Setting. Proceedings from a Conference Held at the Mount Sinai School of Medicine (New York, New York, May 29, 1981).

    ERIC Educational Resources Information Center

    Galli, Nicholas, Ed.; And Others

    These proceedings consist of the texts of eight papers presented at a conference on patient education. Included in the volume are the following conference presentations: "An Educational Framework in the Ambulatory Care Setting," by Jeannette J. Simmons; "The Status of Education in Ambulatory Care: A Report of the American Hospital…

  15. Patient Education: A Better Way to Achieve Compliance in the Ambulatory Care Setting. Proceedings from a Conference Held at the Mount Sinai School of Medicine (New York, New York, May 29, 1981).

    ERIC Educational Resources Information Center

    Galli, Nicholas, Ed.; And Others

    These proceedings consist of the texts of eight papers presented at a conference on patient education. Included in the volume are the following conference presentations: "An Educational Framework in the Ambulatory Care Setting," by Jeannette J. Simmons; "The Status of Education in Ambulatory Care: A Report of the American Hospital…

  16. Aerobic training abolishes ambulatory blood pressure increase induced by estrogen therapy: a double blind randomized clinical trial.

    PubMed

    Cardoso, Crivaldo Gomes; Rosas, Fabrício Collares; Oneda, Bruna; Labes, Eliana; Tinucci, Taís; Abrahão, Sandra Balieiro; da Fonseca, Angela Maggio; Mion, Decio; Forjaz, Cláudia Lúcia de Moraes

    2011-06-01

    Emerging data reveal that oral estrogen therapy can increase clinic blood pressure (BP) in post-menopausal women; however, it is important to establish its effects on ambulatory BP, which is a better predictor for target-organ damage. Besides estrogen therapy, aerobic training is widely recommended for post-menopausal women, and it can decrease ambulatory BP levels. This study was designed to evaluate the effect of aerobic training and estrogen therapy on the ambulatory BP of post-menopausal women. Forty seven healthy hysterectomized women were randomly divided (in a double-blind manner) into 4 groups: placebo-control (PLA-CO=12), estrogen therapy-control (ET-CO=14), placebo-aerobic training (PLA-AT=12), and estrogen therapy-aerobic training (ET-AT=09). The ET groups received estradiol valerate (1 mg/day) and the AT groups performed cycle ergometer, 3×/week at moderate intensity. Hormonal status (blood analysis), maximal cardiopulmonary exercise test (VO(2) peak) and ambulatory BP (24-h, daytime and nighttime) was evaluated before and 6 months after interventions. A significant increase in VO(2) peak was observed only in women who participated in aerobic training groups (+4.6±1.0 ml kg(-1) min(-1), P=0.00). Follicle-stimulating hormone was a significant decreased in the ET groups (-18.65±5.19 pg/ml, P=0.00), and it was accompanied by an increase in circulating estrogen (56.1±6.6 pg/ml). A significant increase was observed in the ET groups for daytime (P=0.01) and nighttime systolic BP (P=0.01), as well as nighttime diastolic BP (P=0.02). However, daytime diastolic BP was increased only in the ET-CO group (+3.4±1.2 mmHg, P=0.04), and did not change in any other groups. No significant effect was found in ambulatory heart rate. In conclusion, aerobic training abolished the increase of daytime ambulatory BP induced by estrogen therapy in hysterectomized, healthy, normotensive and postmenopausal women. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

  17. Impact of a bladder scan protocol on discharge efficiency within a care pathway for ambulatory inguinal herniorraphy.

    PubMed

    Antonescu, I; Baldini, G; Watson, D; Kaneva, P; Fried, G M; Khwaja, K; Vassiliou, M C; Carli, F; Feldman, L S

    2013-12-01

    Postoperative urinary retention (POUR) is a common complication of ambulatory inguinal herniorraphy, with an incidence reaching 38%, and many surgeons require patients to void before discharge. This study aimed to assess whether the implementation of a bladder scan-based voiding protocol reduces the time until discharge after ambulatory inguinal herniorraphy without increasing the rate of POUR. As part of a perioperative care pathway, a protocol was implemented to standardize decision making after elective inguinal hernia repair (February 2012). Patients were assessed with a bladder scan, and those with <600 mL of urine were discharged home, whereas those with more than 600 mL of urine had an in-and-out catheterization before discharge. The patients received written information about urinary symptoms and instructions to present to the emergency department if they were unable to void at home. An audit of scheduled outpatient inguinal hernia repairs between October 2011 and July 2012 was performed. Comparisons were made using the t test, Fisher's exact test, and Wilcoxon rank sum test where appropriate. Statistical significance was defined a priori as a p value lower than 0.05. During the study period, 124 patients underwent hernia repair: 60 before and 64 after implementation of the protocol. The findings showed no significant differences in patient characteristics, laparoscopic approach (35 vs. 33%; p = 0.80), proportion receiving general anesthesia (70 vs. 73%; p = 0.67), or amount of intravenous fluids given (793 vs. 663 mL; p = 0.07). The proportion of patients voiding before discharge was higher after protocol implementation (73 vs. 89%; p = 0.02). The protocol had no impact on median time to discharge (190 vs. 205 min; p = 0.60). Only one patient in each group presented to the emergency department with POUR (2%). After ambulatory inguinal herniorraphy, implementation of a bladder scan-based voiding protocol did not result in earlier discharge. The incidence of

  18. Data Accuracy of the Bubble Sheet Ambulatory Data System and the KG-Ambulatory Data System in the Internal Medicine Clinic, Bayne-Jones Army Community Hospital, Fort Polk, Louisiana

    DTIC Science & Technology

    2000-06-01

    in the Ambulatory Data System (ADS) for the Internal Medicine Clinic at Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. A secondary purpose...Analysis of the financial data indicated that the hospital was minimally at risk for either fraudulent billing or loss of revenue. However, as the Internal ... Medicine Clinic only accounts for 6.3% of outpatient workload, coding behaviors similar to those observed practiced in other high volume clinics would

  19. Measuring Health Literacy among People Living with HIV who attend a Community-Based Ambulatory Clinic in Puerto Rico

    PubMed Central

    Rivero-Méndez, Marta; Suárez-Pérez, Erick L.; Solís-Báez, Solymar S.

    2015-01-01

    Objective Health literacy is an important area for interventions aimed at reducing or eliminating the health disparities of people living with HIV (PLWH). We sought to determine the level of functional health literacy (FHL) and its association with medication adherence, symptoms, and their attendant management strategies in PLWH. Methods This was a cross-sectional study conducted with 200 adults from a community-based ambulatory clinic in San Juan, Puerto Rico. Results The mean age of the participants was 46.61. Almost half of all participants (47%) had marginal or inadequate levels of health literacy (21.5%, n = 23; 25.50%, n = 51, respectively). Educational level, being employed, annual income, having children, incorrect self-reported CD4+T cell counts, were they actually reported their viral loads, adherence to antiretroviral treatment (ART) , and use of self-care strategies for depression were significantly related to a given individual’s level of health literacy (p<0.05). Significant interactions were found between adherence and FHL (p = 0.0069). People with marginal health literacy had a higher mean score (1.77 ± 937) on the adherence scale than did those with inadequate literacy levels. After adjusting for age, education, and the number of people per room at the participant’s home, data showed that for those who were 45 years of age or younger, there were significant differences (p = 0.002) in the mean scores of the adherence scale between those with marginal levels of health literacy and those who had inadequate levels of same (5.66 ± 1.84). Conclusion Findings from this study fill an existing gap in the important area of health literacy among PLWH in Puerto Rico and highlight the importance of conducting future research geared towards incorporating FHL as an essential component in the management of adherence as well as in both symptoms and the management of same in PLWH. PMID:25856875

  20. Measuring health literacy among people living with HIV who attend a community-based ambulatory clinic in Puerto Rico.

    PubMed

    2015-03-01

    Health literacy is an important area for interventions aimed at reducing or eliminating the health disparities of people living with HIV (PLWH). We sought to determine the level of functional health literacy (FHL) and its association with medication adherence, symptoms, and their attendant management strategies in PLWH. This was a cross-sectional study conducted with 200 adults from a community-based ambulatory clinic in San Juan, Puerto Rico. The mean age of the participants was 46.61. Almost half of all participants (47%) had marginal or inadequate levels of health literacy (21.5%, n = 23; 25.50%, n = 51, respectively). Educational level, being employed, annual income, having children, incorrect self-reported CD4+T cell counts, were they actually reported their viral loads, adherence to antiretroviral treatment (ART), and use of self-care strategies for depression were significantly related to a given individual's level of health literacy (p < 0.05). Significant interactions were found between adherence and FHL (p = 0.0069). People with marginal health literacy had a higher mean score (1.77 ± 937) on the adherence scale than did those with inadequate literacy levels. After adjusting for age, education, and the number of people per room at the participant's home, data showed that for those who were 45 years of age or younger, there were significant differences (p = 0.002) in the mean scores of the adherence scale between those with marginal levels of health literacy and those who had inadequate levels of same (5.66 ± 1.84). Findings from this study fill an existing gap in the important area of health literacy among PLWH in Puerto Rico and highlight the importance of conducting future research geared towards incorporating FHL as an essential component in the management of adherence as well as in both symptoms and the management of same in PLWH.

  1. Discordance between ambulatory versus clinic blood pressure according to global cardiovascular risk group.

    PubMed

    Shin, Jinho; Park, Sung Ha; Kim, Ju Han; Ihm, Sang Hyun; Kim, Kwang-il; Kim, Woo Shik; Pyun, Wook Bum; Kim, Yu-Mi; Choi, Sung-il; Kim, Soon Kil

    2015-09-01

    The detection of white coat hypertension (WCH), treated normalized hypertension, and masked hypertension (MH) is important to improve the effectiveness of hypertension management. However, whether global cardiovascular risk (GCR) profile has any effect on the discordance between ambulatory blood pressure (ABP) and clinic blood pressure (CBP) is unknown. Data from 1,916 subjects, taken from the Korean Multicenter Registry for ABP monitoring, were grouped according to diagnostic and therapeutic thresholds for CBP and ABP (140/90 and 135/85 mmHg, respectively). GCR was assessed using European Society of Hypertension 2007 guidelines. The mean subject age was 54.1 ± 14.9 years, and 48.9% of patients were female. The discordancy rate between ABP and CBP in the untreated and treated patients was 32.5% and 26.5%, respectively (p = 0.02). The prevalence of WCH or treated normalized hypertension and MH was 14.4% and 16.0%, respectively. Discordance between ABP and CBP was lower in the very high added-risk group compared to the moderate added-risk group (odds ratio [OR], 0.649; 95% confidence interval [CI], 0.487 to 0.863; p = 0.003). The prevalence of WCH or treated normalized hypertension was also lower in the very high added-risk group (OR, 0.451; 95% CI, 0.311 to 0.655). Discordance between ABP and CBP was observed more frequently in untreated subjects than in treated subjects, and less frequently in the very high added-risk group, which was due mainly to the lower prevalence of WCH or treated normalized hypertension.

  2. The development and use of a new methodology to reconstruct courses of admission and ambulatory care based on the Danish National Patient Registry.

    PubMed

    Gubbels, Sophie; Nielsen, Kenn Schultz; Sandegaard, Jakob; Mølbak, Kåre; Nielsen, Jens

    2016-11-01

    The Danish National Patient Registry (DNPR) contains clinical and administrative data on all patients treated in Danish hospitals. The data model used for reporting is based on standardized coding of contacts rather than courses of admissions and ambulatory care. To reconstruct a coherent picture of courses of admission and ambulatory care, we designed an algorithm with 28 rules that manages transfers between departments, between hospitals and inconsistencies in the data, e.g., missing time stamps, overlaps and gaps. We used data from patients admitted between 1 January 2010 and 31 December 2014. After application of the DNPR algorithm, we estimated an average of 1,149,616 courses of admission per year or 205 hospitalizations per 1000 inhabitants per year. The median length of stay decreased from 1.58days in 2010 to 1.29days in 2014. The number of transfers between departments within a hospital increased from 111,576 to 176,134 while the number of transfers between hospitals decreased from 68,522 to 61,203. We standardized a 28-rule algorithm to relate registrations in the DNPR to each other in a coherent way. With the algorithm, we estimated 1.15 million courses of admissions per year, which probably reflects a more accurate estimate than the estimates that have been published previously. Courses of admission became shorter between 2010 and 2014 and outpatient contacts longer. These figures are compatible with a cost-conscious secondary healthcare system undertaking specialized treatment within a hospital and limiting referral to advanced services at other hospitals. Copyright © 2016 The Author(s). Published by Elsevier Ireland Ltd.. All rights reserved.

  3. Assessing the relationship between patient satisfaction and clinical quality in an ambulatory setting.

    PubMed

    Bosko, Tawnya; Wilson, Kathryn

    2016-10-10

    Purpose The purpose of this paper is to assess the relationship between patient satisfaction and a variety of clinical quality measures in an ambulatory setting to determine if there is significant overlap between patient satisfaction and clinical quality or if they are separate domains of overall physician quality. Assessing this relationship will help to determine whether there is congruence between different types of clinical quality performance and patient satisfaction and therefore provide insight to appropriate financial structures for physicians. Design/methodology/approach Ordered probit regression analysis is conducted with overall rating of physician from patient satisfaction responses to the Clinician and Groups Consumer Assessment of Healthcare Providers and Systems survey as the dependent variable. Physician clinical quality is measured across five composite groups based on 26 Healthcare Effectiveness Data and Information Set (HEDIS) measures aggregated from patient electronic health records. Physician and patient demographic variables are also included in the model. Findings Better physician performance on HEDIS measures are correlated with increases in patient satisfaction for three composite measures: antibiotics, generics, and vaccination; it has no relationship for chronic conditions and is correlated with decrease in patient satisfaction for preventative measures, although the negative relationship for preventative measures is not robust in sensitivity analysis. In addition, younger physicians and male physicians have higher satisfaction scores even with the HEDIS quality measures in the regression. Research limitations/implications There are four primary limitations to this study. First, the data for the study come from a single hospital provider organization. Second, the survey response rate for the satisfaction measure is low. Third, the physician clinical quality measure is the percent of the physician's relevant patient population that met

  4. Insights into the contemporary management of heart failure in specialized multidisciplinary ambulatory clinics.

    PubMed

    Abrahamyan, Lusine; Trubiani, Gina; Witteman, William; Mitsakakis, Nicholas; Krahn, Murray; Wijeysundera, Harindra C

    2013-09-01

    Heart failure (HF) clinics are associated with improved outcomes in randomized trials, however, there is substantial heterogeneity in the service models of HF clinics in practice. Our objective was to evaluate the effect of this clinic level heterogeneity on HF patient management in Ontario, Canada. Charts were abstracted from 9 HF clinics, chosen at random from the 34 HF clinics in operation in Ontario in 2011. From each clinic, approximately 100 patient charts were randomly selected for detailed abstraction on patient demographic characteristics, comorbidities, diagnostic tests, medication use, and referrals, over a 1-year period from the first clinic visit. Significant heterogeneity was observed in patient baseline profiles, pharmacological therapies, diagnostic testing, clinic personnel, and referrals across 9 clinics. The mean age of patients was 66.1 ± 15.7 years and was significantly different between the clinics. Most patients were male (65%), and mean left ventricular ejection fraction was 33%. There was significant variation in the utilization of echocardiography (42%-94%) and coronary angiography (19%-62%). Overall, approximately 88% of patients were prescribed angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers, and 85% were prescribe β-blockers. The rates of referral to cardiac rehabilitation programs were overall low at 10.4% of patients, with substantial variation (1%-28%). Specialized HF clinics have wide variation in the health personnel involved and the care provided; in addition, patients treated at these HF clinics have important differences in clinical characteristics. Strategies should be considered at the appropriate level (eg, province-wide in Ontario) to standardize HF management and provide best evidence-based care to patients. Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

  5. Missing clinical information during primary care visits.

    PubMed

    Smith, Peter C; Araya-Guerra, Rodrigo; Bublitz, Caroline; Parnes, Bennett; Dickinson, L Miriam; Van Vorst, Rebecca; Westfall, John M; Pace, Wilson D

    2005-02-02

    The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical information has not been explicitly investigated in the primary care setting. To describe primary care clinicians' reports of missing clinical information. Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded. Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering. Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10

  6. [Ambulatory esophageal pH monitoring: critical review of methodology: (equipment, reproducibility, standards), clinical importance and personal experience].

    PubMed

    Jonard, P; Fiasse, R; Tomé, G; Dive, C

    1990-01-01

    The authors review the recent literature about the methodology of oesophageal pH monitoring, which has a high sensitivity and a high specificity for assessing gastro-oesophageal reflux. Combined electrodes offer most advantages. Ambulatory recording should be done in hospital under standard conditions (meals), particularly for clinical studies. The best clinical indication is to detect pathological reflux in case of atypical symptoms with negative oesophagoscopy. The authors give their normal values in a series of measurements with two systems as well as their results in a series of cases of oesophagitis of various grades.

  7. Comparison of new continuous measurements of ambulatory venous pressure (AVP) with conventional tiptoe exercise ambulatory AVP in relation to the CEAP clinical classification of chronic venous disease.

    PubMed

    Eifell, Ron K G; Ashour, Hamdy Y; Lees, Tim A

    2006-10-01

    Quantitative measurements of chronic venous insufficiency (CVI) are sensitive in detecting the presence of CVI but have low specificity in differentiating clinical severities of CVI as defined by the CEAP classification. One possible reason for this is measurement techniques do not assess variables that reflect hemodynamic changes that occur during normal exercise. Our aim was to compare the association of variables determined from a new technique, continuous ambulatory venous pressure monitoring (CAVPM), and those of conventional AVP measurement with the clinical severity of chronic venous insufficiency in patients with primary venous reflux. Fifty-four limbs of 49 patients with CVI and 15 healthy controls were studied. CVI clinical severity was classified according to CEAP as C2&C3 (mild disease), C4 (moderate disease), and C5&C6 (severe disease). All participants underwent duplex ultrasound scanning to rule out the presence of reflux in the control group and to confirm it in the patient groups. Conventional AVP measurements, including 90% refilling time (RT90), were compared with the new CAVP variables of mean walking pressure (MWP) and percentage fall in walking pressure (%FWP). Data were analyzed by analysis of variance using the Kruskal-Wallis test, and comparisons between groups were performed using Mann-Whitney tests. Discriminant analysis was used to determine the ability of a test to classify limbs into clinical classes. Conventional AVP measurements could not differentiate between the control group and the presence of mild disease (P = .56) but did differentiate between controls and severe disease as well as mild and severe disease (P < .001). RT90 detected differences between controls and reflux groups (P < .001) but not between moderate (C4) and severe (C5&C6) clinical groups (P > .5). MWP and %FWP showed significant differences between all clinical severities and controls (P < .001). In the assessment of CVI, mean walking pressure and percent fall in

  8. Ambulatory Assessment

    PubMed Central

    Trull, Timothy J.; Ebner-Priemer, Ulrich

    2014-01-01

    Ambulatory assessment (AA) covers a wide range of assessment methods to study people in their natural environment, including self-report, observational, and biological/physiological/behavioral. AA methods minimize retrospective biases while gathering ecologically valid data from patients’ everyday life in real time or near real time. Here, we report on the major characteristics of AA, and we provide examples of applications of AA in clinical psychology (a) to investigate mechanisms and dynamics of symptoms, (b) to predict the future recurrence or onset of symptoms, (c) to monitor treatment effects, (d) to predict treatment success, (e) to prevent relapse, and (f) as interventions. In addition, we present and discuss the most pressing and compelling future AA applications: technological developments (the smartphone), improved ecological validity of laboratory results by combined lab-field studies, and investigating gene-environment interactions. We conclude with a discussion of acceptability, compliance, privacy, and ethical issues. PMID:23157450

  9. Clinical validation of the accutracker, a novel ambulatory blood pressure monitor using R-wave gating for Korotkoff sounds.

    PubMed

    White, W B; Schulman, P; McCabe, E J; Nardone, M B

    1987-12-01

    We compared simultaneous, same-arm blood pressure (BPs) obtained with the Accutracker, an ambulatory blood pressure (BP) monitor, which uses R-wave gating for Korotkoff sounds to those of both a blinded, skilled clinician using a mercury column and a three-channel graphic display of cuff pressure tracings, Korotkoff sounds, and ECG tracing. Eighteen subjects, with a wide variety of BPs, heart rates, and ages, participated in the study. The systolic BP obtained by the ambulatory recorder, clinician, and the three-channel strip chart recorder were 132 +/- 23 mmHg, 132 +/- 24 mmHg, and 133 +/- 25 mmHg, (all NS), respectively. Accutracker recorder-determined systolic BP correlated highly both with the clinician and strip chart readings (r = 0.98 and 0.97, respectively; p less than 0.0001 for both). The diastolic BP obtained by the Accutracker recorder was slightly, but significantly, lower than the clinician's readings (76 +/- 12 mmHg vs. 81 +/- 13 mmHg; p less than 0.005) and similar to the strip chart recorder readings (76 +/- 12 mmHg vs. 77 +/- 12 mmHg; NS). In 32 young, healthy subjects with no activity restrictions, 91% of the raw BP data from 24-hour ambulatory recordings was acceptable using strict deletion criteria. These data demonstrate that the Accutracker is highly accurate compared with clinician-determined blood pressures. The lower diastolic BP readings may stem from the ability of this device to detect softer Korotkoff sounds than can be detected by the clinician. These findings should be taken into consideration when using ambulatory BP monitoring in clinical trials of antihypertensive drugs.

  10. High-Intensity Telemedicine Decreases Emergency Department Use for Ambulatory Care Sensitive Conditions by Older Adult Senior Living Community Residents.

    PubMed

    Shah, Manish N; Wasserman, Erin B; Gillespie, Suzanne M; Wood, Nancy E; Wang, Hongyue; Noyes, Katia; Nelson, Dallas; Dozier, Ann; McConnochie, Kenneth M

    2015-12-01

    Emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) are common among older adults. The high-intensity telemedicine model of care has been proposed as an innovative approach to expand access to acute illness care, thereby preventing ED visits. The aim of this study was to assess the effect of a high-intensity telemedicine program for senior living community (SLC) residents on the rate of ED use for ACSCs. We performed a prospective cohort study at a primary care geriatrics practice that provides care to 22 SLCs. Six SLCs selected as intervention facilities, with the remaining SLCs serving as controls. Consenting practice patients at intervention facilities could have patient-to-provider, real-time, or store-and-forward high-intensity telemedicine services to diagnose and treat illnesses. The primary outcome was the rate of ED visits for which the primary diagnosis was an "ambulatory-care-sensitive" condition by the Institute of Medicine, which we compared between control and intervention participants. During the study period, control participants had 310 ED visits for ACSCs, for a rate of 0.195 visits/person-year. Intervention participants visited the ED for ACSCs 85 times, for a rate of 0.138 visits/person-year [unadjusted rate ratio (RR): 0.71, 95% confidence interval (CI): 0.53-0.94]. Among intervention participants, ED use for ACSCs decreased at an annual rate of 34% (RR: 0.661, 95% CI: 0.444-0.982), whereas, in the control group there was no statistically significant change in ED use over time (RR: 1.01, 95% CI: 0.90-1.14). Providing acute illness care by high-intensity telemedicine to older adults residing in SLCs significantly decreases the rate of ED use for ACSCs over 1 year, compared with no change in the rate of ED use for ACSCs among the control group. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

  11. Surveillance of Physicians Causing Potential Drug-Drug Interactions in Ambulatory Care: A Pilot Study in Switzerland

    PubMed Central

    Bucher, Heiner C.; Achermann, Rita; Stohler, Nadja; Meier, Christoph R.

    2016-01-01

    Objectives We analysed potential drug-drug interactions (DDI) in ambulatory care in Switzerland based on claims data from three large health insurers in 2010 to identify physicians with peculiar prescription behaviour differing from peers of the same specialty. Methods We analysed contraindicated or potentially contraindicated DDI from the national drug formulary and calculated for each physician the ratios of the number of patients with a potential DDI divided by the number of patients at risk and used a zero inflated binomial distribution to correct for the inflated number of observations with no DDI. We then calculated the probability that the number of caused potential DDI of physicians was unlikely (p-value < 0.05 and ≥0.01) and very unlikely (p-value <0.01) to be due to chance. Results Of 1'607'233 females and 1'525'307 males 1.3% and 1.2% were exposed to at least one potential DDI during 12 months. When analysing the 40 most common DDI, 598 and 416 of 18,297 physicians (3.3% and 2.3%) were causing potential DDI in a frequency unlikely (p<0.05 and p≥0.01) and very unlikely (p<0.01) to be explained by chance. Patients cared by general practitioners and cardiologists had the lowest probability (0.20 and 0.26) for not being exposed to DDI. Conclusions Contraindicated or potentially contraindicated DDI are frequent in ambulatory care in Switzerland, with a small proportion of physicians causing potential DDI in a frequency that is very unlikely to be explained by chance when compared to peers of the same specialty. PMID:26808430

  12. Treatment of Atopic Dermatitis in the United States: Analysis of Data from the National Ambulatory Medical Care Survey.

    PubMed

    McGregor, Sean P; Farhangian, Michael E; Huang, Karen E; Feldman, Steven R

    2017-03-01

    Introduction: Atopic dermatitis (AD) affects both adult and pediatric patients, and multiple practitioners encounter and manage AD. However, differences with regard to the treatment of AD between specialties are not well characterized. The primary objective of this study was to determine if there is a difference between dermatologists and non-dermatology specialties with regard to treatment strategies for AD and to describe those differences. Data from the 1993-2010 National Ambulatory Medical Care (NAMCS) and National Hospital Ambulatory Care (NHAMCS) Surveys were used to characterize outpatient visits made for AD. Differences in demographic, geographic and seasonal characteristics were obtained and compared. Additionally, the frequency of medications prescribed at dermatologist visits were compared to other specialties. Frequency of modalities used in the treatment of atopic dermatitis between dermatologists and non-dermatology specialties. An estimated 3.7 million visits for AD were made to outpatient offices and hospital departments from 1993 to 2010. The rates per capita of visits for atopic dermatitis were similar when evaluated by gender and season. However, Caucasians were almost 50% less likely than African Americans or individuals of other minority races to have visits for AD. Topical corticosteroids (TCS) were mentioned at 52% of visits, and dermatologists were more likely than non-dermatologists to prescribe TCS, emollients, and topical calcineurin inhibitors. Dermatologists were more likely to recommend TCS, emollients, and topical calciuneurin inhibitors for the treatment of AD. Dermatologists were also more likely to prescribe higher potency TCS in comparison to non-dermatology specialties, and these differences may ultimately affect patient care. As a result, there remains a disparity between dermatologists and non-dermatology specialties with regard to evidence-based approaches to the treatment of AD.

    J Drugs Dermatol. 2017

  13. [The medical social aspects of ambulatory medical care to victims of road traffic accidents].

    PubMed

    Gorbunkov, V Ia; Bugaev, D A; Derevianko, D V

    2012-01-01

    The article discusses the issues of the organization of medical care to victims of road traffic accidents. The analysis of primary appealability of patients to the first-aid center of Stavropol and Novorossiysk during 2008-2010 is presented. The sampling consisted of 904 cases of this kind of trauma. It is established that among victims of road traffic accident appealed to first-aid centers the pedestrians consist the major part. The traumas of limbs are among the most frequently occurred cases. The victims with cranio-cerebral injuries are among those who appealed most frequently for medical aid. Besides that in most cases (63.4%) the victims with cranio-cerebral injuries were transported not to the neurologic surgery clinic but to the first-aid center This action increased the number of transport stages and duration of time gap before specialized medical care was applied. The conclusion is made concerning the need of further development of out-patient urgent medical care to victims of road traffic accidents.

  14. Patient visits to a national practice-based research network: comparing pediatric research in office settings with the National Ambulatory Medical Care Survey.

    PubMed

    Slora, Eric J; Thoma, Kathleen A; Wasserman, Richard C; Pedlow, Steven E; Bocian, Alison B

    2006-08-01

    Our objective with this study was to assess the extent to which patients who are seen by practitioners in Pediatric Research in Office Settings, a national primary care practice-based research network, are representative of those who are seen in ambulatory office-based pediatric primary care in the United States. Pediatric Research in Office Settings patient data were collected from the offices of 57 randomly selected network practitioners as part of an Agency for Healthcare Research and Quality-funded effort to describe primary care visits and replicate the National Ambulatory Medical Care Survey in primary care practice-based research networks. These data were from 1706 randomly selected pediatric patient visits that occurred between March and June 2002. National comparison data were 948 randomly selected pediatric patient visits that occurred between March and June 2000 in the offices of the 33 primary care pediatric practitioners who had participated in the National Ambulatory Medical Care Survey. The groups were compared on patient demographics (age, gender, race, ethnicity, and socioeconomic status, as represented by Medicaid status), visit characteristics (percentages of patients referred, practitioner designation of visit as acute versus nonacute, and continuity of care), the top patient/parent-articulated reasons for visit, and the top practitioner diagnoses. Comparisons revealed substantial similarities between Pediatric Research in Office Settings and national data, including gender, ethnicity, socioeconomic status, and visit characteristics. Differences were noted for age and race, with Pediatric Research in Office Settings children approximately 1 year older and comprising a significantly lower proportion of black patients than their National Ambulatory Medical Care Survey counterparts. Although the top 6 reasons that were articulated by parents for outpatient visits in the 2 groups were remarkably similar in rank order and proportions, there were

  15. The validation of a care partner-derived frailty index based upon comprehensive geriatric assessment (CP-FI-CGA) in emergency medical services and geriatric ambulatory care.

    PubMed

    Goldstein, Judah; Hubbard, Ruth E; Moorhouse, Paige; Andrew, Melissa K; Mitnitski, Arnold; Rockwood, Kenneth

    2015-03-01

    The derivation of a frailty index (FI) based on deficit accumulation from a Comprehensive Geriatric Assessment (CGA) has been criticised as cumbersome. To improve feasibility, we developed a questionnaire based on a CGA that can be completed by care partners (CP-FI-CGA) and assessed its validity. We enrolled a convenience sample of patients aged 70 or older (n=203) presenting to emergency medical services (EMS) or geriatric ambulatory care (GAC). To test construct validity, we evaluated the shape of the CP-FI-CGA distribution, including its maximum value, relationship with age and gender. Criterion validity was evaluated by survival analysis and by the correlation between the CP-FI-CGA and specialist-completed FI-CGA. The mean age was 82.2±5.9 years. Most patients were women (62.1%), unmarried (widowed, divorced and single) (59.6%) and lived in their own home or apartment (78.3%). The mean CP-FI-CGA was 0.41±0.15 and was higher in the EMS group (0.45±0.15) than in GAC (0.37±0.14) (P<0.001). The CP-FI-CGA correlated well with the specialist-completed FI-CGA (0.7; P<0.05). People who died had a higher CP-FI-CGA than did survivors (0.48±0.13 versus 0.38±0.15). Each 0.01 increase in the FI was associated with a higher risk of death (HR 1.04; 95% CI 1.02-1.06). The CP-FI-CGA has properties that resemble other published FIs and may be useful in busy clinical practice for grading degrees of frailty. It efficiently integrates information from care partners so that it can help guide decision-making. © The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  16. [THE ACCESSIBILITY OF ORGANIZATION OF PRIMARY MEDICAL SANITARY CARE DURING THE PERIOD OF REFORMING OF AMBULATORY POLYCLINIC INSTITUTIONS OF METROPOLITAN REGION].

    PubMed

    Gridnev, O V; Zagoruichenko, A A

    2015-01-01

    The article presents materials of sociological evaluation of organization of primary medical sanitary care within the framework of implementation of three-level system. The technique of non-formalized sociological interview was applied. The positive and negative aspects are presented exemplified by ambulatory centers and their subdivisions providing health services to adult population of the North East administrative okrug of Moscow.

  17. National Ambulatory Medical Care Survey: Background and Methodology. United States-1967-72. Vital and Health Statistics. Data Evaluation and Methods Research. Series 2, No. 61.

    ERIC Educational Resources Information Center

    National Center for Health Statistics (DHEW/PHS), Hyattsville, MD.

    The report describes the initial design and the preliminary background exploration, subsequent development, and feasibility testing of methods for conducting a continuing National Ambulatory Medical Care Survey (NAMCS). Selected feasibility study findings are presented to illustrate collected data and suggest kinds of information that may be…

  18. Studies in Ambulatory Care Quality Assessment in the Indian Health Service. Volume III: Comparison of Rural Private Practice, Health Maintenance Organizations, and the Indian Health Service.

    ERIC Educational Resources Information Center

    Nutting, Paul A.; And Others

    Utilizing a quality assessment methodology for ambulatory patient care currently under development by the Indian Health Service's (IHS) Office of Research and Development, comparisons were made between results derived from a pilot test in IHS service units, 2 metropolitan Health Maintenance Organizations (HMO), and 3 rural private practices.…

  19. Clinical informatics in critical care.

    PubMed

    Martich, G Daniel; Waldmann, Carl S; Imhoff, Michael

    2004-01-01

    Health care information systems have the potential to enable better care of patients in much the same manner as the widespread use of the automobile and telephone did in the early 20th century. The car and phone were rapidly accepted and embraced throughout the world when these breakthroughs occurred. However, the automation of health care with use of computerized information systems has not been as widely accepted and implemented as computer technology use in all other sectors of the global economy. In this article, the authors examine the need, risks, and rewards of clinical informatics in health care as well as its specific relationship to critical care medicine.

  20. Prognostic impact of clinic and ambulatory blood pressure components in high-risk type 2 diabetic patients: the Rio de Janeiro Type 2 Diabetes Cohort Study.

    PubMed

    Salles, Gil F; Leite, Nathalie C; Pereira, Basílio B; Nascimento, Emilia M; Cardoso, Claudia R L

    2013-11-01

    The prognostic importance of tight clinic blood pressure (BP) control is controversial in diabetic patients. The objective was to investigate the prognostic impact of clinic and ambulatory BPs for cardiovascular morbidity and mortality in type 2 diabetes. In a prospective cohort study, 565 type 2 diabetic patients had clinical, laboratory and ambulatory BP monitoring (ABPM) data obtained at baseline and during follow-up. The primary endpoints were a composite of fatal and nonfatal cardiovascular events and all-cause mortality. Multivariable Cox survival and splines regression analyses assessed associations between each BP component [SBP, DBP and pulse pressure (PP)] and the endpoints. After a median follow-up of 5.75 years, 88 total cardiovascular events and 70 all-cause deaths occurred. After adjustments for cardiovascular risk factors, clinic SBP and DBPs were predictive of the composite endpoint but not of all-cause mortality, whereas all ambulatory BP components were predictors of both endpoints. Ambulatory systolic and PPs were the strongest predictors and achieved ambulatory BPs during follow-up improved risk prediction in relation to baseline values. When categorized at clinically relevant cut-off values, risk began only at clinic BPs at least 140/90 mmHg, whereas for ambulatory BPs it began at lower values (≥120/75 mmHg for the 24-h period). ABPM provides more valuable information regarding cardiovascular risk stratification than office BPs and should be performed, if possible, in every high-risk type 2 diabetic patient. Achieved 24-h ambulatory BPs less than 120/75 mmHg are associated with significant cardiovascular protection and, if confirmed by other studies, may be considered as BP treatment targets.

  1. Potential drug-drug and drug-disease interactions in prescriptions for ambulatory patients over 50 years of age in family medicine clinics in Mexico City

    PubMed Central

    Doubova (Dubova), Svetlana Vladislavovna; Reyes-Morales, Hortensia; Torres-Arreola, Laura del Pilar; Suárez-Ortega, Magdalena

    2007-01-01

    Background In Mexico, inappropriate prescription of drugs with potential interactions causing serious risks to patient health has been little studied. Work in this area has focused mainly on hospitalized patients, with only specific drug combinations analyzed; moreover, the studies have not produced conclusive results. In the present study, we determined the frequency of potential drug-drug and drug-disease interactions in prescriptions for ambulatory patients over 50 years of age, who used Mexican Institute of Social Security (IMSS) family medicine clinics. In addition, we aimed to identify the associated factors for these interactions. Methods We collected information on general patient characteristics, medical histories, and medication (complete data). The study included 624 ambulatory patients over 50 years of age, with non-malignant pain syndrome, who made ambulatory visits to two IMSS family medicine clinics in Mexico City. The patients received 7-day prescriptions for non-opioid analgesics. The potential interactions were identified by using the Thompson Micromedex program. Data were analyzed using descriptive, bivariate and multiple logistic regression analyses. Results The average number of prescribed drugs was 5.9 ± 2.5. About 80.0% of patients had prescriptions implying one or more potential drug-drug interactions and 3.8% of patients were prescribed drug combinations with interactions that should be avoided. Also, 64.0% of patients had prescriptions implying one or more potential drug disease interactions. The factors significantly associated with having one or more potential interactions included: taking 5 or more medicines (adjusted Odds Ratio (OR): 4.34, 95%CI: 2.76–6.83), patient age 60 years or older (adjusted OR: 1.66, 95% CI: 1.01–2.74) and suffering from cardiovascular diseases (adjusted OR: 7.26, 95% CI: 4.61–11.44). Conclusion The high frequency of prescription of drugs with potential drug interactions showed in this study suggests that

  2. Implementation and evaluation of a gravimetric i.v. workflow software system in an oncology ambulatory care pharmacy.

    PubMed

    Reece, Kelley M; Lozano, Miguel A; Roux, Ryan; Spivey, Susan M

    2016-02-01

    The implementation and evaluation of a gravimetric i.v. workflow software system in an oncology ambulatory care pharmacy are described. To estimate the risk involved in the sterile i.v. compounding process, a failure modes and effects analysis (FMEA) in the oncology ambulatory care pharmacy was performed. When a volumetric-based process was used to reconstitute vials, the actual concentration was unknown since an assumption must be made that the exact volume of diluent was used when reconstituting the drug. This gap in our process was discovered during the FMEA and was resolved with the implementation of an i.v. workflow software solution. The i.v. software system standardized preparation steps and documented each process step, enabling a systematic review of the metrics for safety, productivity, and drug waste. Over the study period, 15,843 doses were prepared utilizing the new technology, with a total of 1,126 errors (7%) detected by the workflow software during dose preparation. Barcode scanning detected 292 (26%) of the total errors, the gravimetric weighing step detected 797 (71%) deviation errors, and 37 (3%) errors were detected at the vial reconstitution step. All errors were detected during compounding, eliminating the need to correct errors after production. Technician production time decreased by 34%, and pharmacist checking time decreased by 37%. Implementation of a gravimetric-based software system that used barcode verification and real-time alerts improved the detection of errors in the chemotherapy preparation process when compared with self-reporting. Standardized workflow processes and the elimination of time-consuming manual steps increased productivity while vial management decreased costs. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

  3. Older Adults’ Inpatient and Emergency Department Utilization For Ambulatory-Care-Sensitive Conditions: Relationship with Alcohol Consumption

    PubMed Central

    Levy Merrick, Elizabeth S.; Hodgkin, Dominic; Garnick, Deborah W.; Horgan, Constance M.; Panas, Lee; Ryan, Marian; Blow, Frederic C.; Saitz, Richard

    2010-01-01

    Objectives This study examined the relationship between drinking that exceeds guideline-recommended limits and acute-care utilization for ambulatory-care-sensitive conditions (ACSCs) by older Medicare beneficiaries. Methods This secondary data analysis utilized the 2001–2006 Medicare Current Beneficiary Survey (unweighted n=5,570 community dwelling, past-year drinkers, 65 years and older). Self-reported alcohol consumption (categorized as within-guidelines, exceeding monthly but not daily limits, or heavy episodic) and covariates were used to predict ACSC hospitalization, emergency department visit not resulting in admission, and emergency department visit that did result in admission. Results Heavy episodic drinking was significantly associated with higher likelihood of an ACSC emergency department visit not resulting in admission (adjusted odds ratio 1.91, 95% CI 1.11 – 3.30; p<.05). Drinking pattern was not significant for other ACSC measures. Discussion Results partially support the hypothesis that excessive drinking may be related to ACSC acute-care utilization among older adults, suggesting increased risk of lower-quality outpatient care. PMID:20935248

  4. Factors associated with pneumonia in Yanomami children hospitalized for Ambulatory Care sensitive conditions in the north of Brazil.

    PubMed

    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.

  5. Primary Care Clinics and Accountable Care Organizations

    PubMed Central

    Tang, Chiung-Ya; Lin, Yi-Ling; Masri, Maysoun Dimachkie

    2016-01-01

    Background The Accountable Care Organization (ACO) is one of the new models of health care delivery in the U.S. To date, little is known about the characteristics of health care organizations that have joined ACOs. We report on the findings of a survey of primary care clinics, the objective of which was to investigate the opinions of clinic management about participation in ACOs, and the characteristics of clinic organizational structure that may contribute to joining ACOs or be willing to do so. Methods A 27-item survey questionnaire was developed and distributed by mail in 3 annual waves to all Rural Health Clinics (RHCs) in 9 states. Two dependent variables - participation in ACOs and willingness to join ACOs - were created and analyzed using a generalized estimating equation (GEE) approach. Results 257 RHCs responded to the survey. A small percentage (5.2%) of the respondent clinics reported that they were participating in ACOs. RHCs in isolated areas were 78% less likely to be in ACOs (odds= 0.22, p= 0.059). Non-profit RHCs indicated a higher willingness to join an ACO than for-profit RHCs (B= 1.271, p= 0.054). There is a positive relationship between RHC size and willingness to join an ACO (B= 0.402, p=0.010). Conclusions At this early stage of ACO development, many RHC personnel are unfamiliar with the ACO model. Rural providers’ limited technological and human resources, and the lack of ACO development in rural areas, may delay or prevent their participation in ACOs. PMID:26900587

  6. Quality of care at retail clinics for 3 common conditions.

    PubMed

    Shrank, William H; Krumme, Alexis A; Tong, Angela Y; Spettell, Claire M; Matlin, Olga S; Sussman, Andrew; Brennan, Troyen A; Choudhry, Niteesh K

    2014-10-01

    Evaluation of quality of care across retail clinics in a geographically diverse population has not been undertaken to date. We sought to evaluate and compare the quality of care for otitis media, pharyngitis, and urinary tract infection received in retail medical clinics in CVS pharmacies ("MinuteClinics" [MCs]), ambulatory care facilities (ACFs), and emergency departments (EDs). We used 14 measures constructed from RAND Corporation's Quality Assurance Tools and guidelines from the American Academy of Pediatrics, the American Academy of Family Physicians, and the Infectious Diseases Society of America. Our cohort was drawn from Aetna medical and prescription claims, 2009-2012. Members were matched on visit date, condition, and propensity score. Generalized estimating equations were used to compare quality across clinic type, overall, and by index condition. We matched 75,886 episodes of care, of which 20,153 were eligible for at least 1 quality measure. MCs performed better than EDs and ACFs in 7 measures. In a multivariable model, MCs performed better than ACFs and EDs across all quality measures ([OR 0.42; 95% CI, 0.40-0.45; P < .0001; ACF vs MC] [OR 0.29; 95% CI, 0.27-0.31; P < .0001; ED vs MC]). Results for each condition were significant at P < .0001. Quality of care for these conditions based on widely accepted objective measures was superior in MinuteClinics compared with ACFs and EDs.

  7. A comparison of medical record with billing diagnostic information associated with ambulatory medical care.

    PubMed Central

    Studney, D R; Hakstian, A R

    1981-01-01

    The degree of similarity between diagnostic information furnished with claims and that simultaneously entered into the medical record was estimated for 1,215 private office visits in British Columbia, Canada. For each visit, claim card and chart diagnoses were compared by having three independent internists (blinded to source and type of the data) make judgments about each diagnostic pair. The judges were highly consistent internally and their judgments were stable over time. In 40 per cent of cases chart and claims data were judged dissimilar, and in 38 per cent of cases claims data were judged more valuable as a reflection of the primary problem treated. The degree of judged similarity of chart and claims data correlated significantly and negatively with physician workload, income, and judges' preference for the billing card diagnosis. We conclude that in using claims data to determine the content of ambulatory visits, independent validation of such data may be important. PMID:7457683

  8. The Cleveland Clinic Experience with Supraclavicular and Popliteal Ambulatory Nerve Catheters

    PubMed Central

    Gharabawy, Ramez; Eid, Gamal; Mendoza, Maria; Mounir-Soliman, Loran; Ali Sakr Esa, Wael

    2014-01-01

    Continuous peripheral nerve blocks (CPNB) are commonly used for intraoperative and postoperative analgesia. Our study aimed at describing our experience with ambulatory peripheral nerve catheters. After Institutional Review Board approval, records for all patients discharged with supraclavicular or popliteal catheters between January 1, 2009 and December 31, 2011 were reviewed. A licensed practitioner provided verbal and written instructions to the patients prior to discharge. Daily follow-up phone calls were conducted. Patients either removed their catheters at home with real-time simultaneous telephone guidance by a member of the Acute Pain Service or had them removed by the surgeon during a regular office visit. The primary outcome of this analysis was the incidence of complications, categorized as pharmacologic, infectious, or other. The secondary outcome measure was the average daily pain score. Our study included a total of 1059 patients with ambulatory catheters (769 supraclavicular, 290 popliteal). The median infusion duration was 5 days for both groups. Forty-two possible complications were identified: 13 infectious, 23 pharmacologic, and 6 labeled as other. Two patients had retained catheters, 2 had catheter leakage, and 2 had shortness of breath. Our study showed that prolonged use of ambulatory catheters for a median period of 5 days did not lead to an increased incidence of complications. PMID:25535627

  9. The Cleveland Clinic experience with supraclavicular and popliteal ambulatory nerve catheters.

    PubMed

    Gharabawy, Ramez; Abd-Elsayed, Alaa; Elsharkawy, Hesham; Farag, Ehab; Cummings, Kenneth; Eid, Gamal; Mendoza, Maria; Mounir-Soliman, Loran; Rosenquist, Richard; Ali Sakr Esa, Wael

    2014-01-01

    Continuous peripheral nerve blocks (CPNB) are commonly used for intraoperative and postoperative analgesia. Our study aimed at describing our experience with ambulatory peripheral nerve catheters. After Institutional Review Board approval, records for all patients discharged with supraclavicular or popliteal catheters between January 1, 2009 and December 31, 2011 were reviewed. A licensed practitioner provided verbal and written instructions to the patients prior to discharge. Daily follow-up phone calls were conducted. Patients either removed their catheters at home with real-time simultaneous telephone guidance by a member of the Acute Pain Service or had them removed by the surgeon during a regular office visit. The primary outcome of this analysis was the incidence of complications, categorized as pharmacologic, infectious, or other. The secondary outcome measure was the average daily pain score. Our study included a total of 1059 patients with ambulatory catheters (769 supraclavicular, 290 popliteal). The median infusion duration was 5 days for both groups. Forty-two possible complications were identified: 13 infectious, 23 pharmacologic, and 6 labeled as other. Two patients had retained catheters, 2 had catheter leakage, and 2 had shortness of breath. Our study showed that prolonged use of ambulatory catheters for a median period of 5 days did not lead to an increased incidence of complications.

  10. Why Do Patients Seek Care at Retail Clinics and What Alternatives Did They Consider

    PubMed Central

    Wang, Margaret C; Ryan, Gery; McGlynn, Elizabeth A; Mehrotra, Ateev

    2012-01-01

    Retail clinics are an increasingly popular new model of ambulatory care. To understand why patients seek care at these clinics and what their experiences were like, we interviewed 61 patients at six retail clinics. Patients were satisfied with the overall experience and were attracted to retail clinics because of their convenient location and fixed, transparent pricing. Patients with a primary care provider (PCP) sought care at these clinics primarily because their PCPs were not available in a timely manner. If retail clinics were not available, a quarter of patients report they would have gone to the emergency department. Retail clinics appear to be responding to the need for convenient, affordable, and consumer-centered care. PMID:20142442

  11. Impact of pharmacist integration in a pediatric primary care clinic on vaccination errors: a retrospective review.

    PubMed

    Haas-Gehres, Anna; Sebastian, Sonya; Lamberjack, Kristen

    2014-01-01

    To measure the impact of ambulatory clinical pharmacist integration in a pediatric primary care clinic on vaccination error rates and to evaluate missed opportunities. A retrospective, quasi-experimental review of electronic medical records of visit encounters during a 3-month period compared vaccine error rates and missed opportunities between two pediatric residency primary care clinics. The intervention clinic has a full-time ambulatory clinical pharmacist integrated into the health care team. Pharmacy services were not provided at the comparison clinic. A vaccine error was defined as follows: doses administered before minimum recommended age, doses administered before minimum recommended spacing from a previous dose, doses administered unnecessarily, live virus vaccination administered too close to a previous live vaccine, and doses invalid for combinations of these reasons. 900 encounters were randomly selected and reviewed. The error rate was found to be 0.28% in the intervention clinic and 2.7% in the comparison clinic. The difference in error rates was found to be significant (P = 0.0021). The number of encounters with greater than or equal to one missed opportunity was significantly higher in the comparison clinic compared with the intervention clinic (29.3% vs. 10.2%; P <0.0001). The pediatric primary care clinic with a pharmacist had reductions in vaccination errors as well as missed opportunities. Pharmacists play a key role in the pediatric primary care team to improve the appropriate use of vaccines.

  12. Preconsultation exchange for ambulatory hepatology consultations

    PubMed Central

    Sewell, Justin L.; Guy, Jennifer; Kwon, Annette; Hm Chen, Alice; Yee, Hal F.

    2013-01-01

    Background Preconsultation exchange is an emerging model of specialty care proposed by the American College of Physicians that seeks to answer a clinical question without a formal patient visit to the specialty clinic. This form of specialty care has been little studied. We sought to determine the appropriateness of preconsultation exchange for ambulatory hepatology consultations within our urban healthcare system. Methods Retrospective study of referrals for ambulatory hepatology consultation in the safety net healthcare system of San Francisco, CA from January 2007 through April 2010. Results Of the 500 referrals reviewed, 87 were excluded as repeat requests. The most common reasons for referral were hepatitis B (34.9%) and hepatitis C (32.0%). 56 referrals (13.6%) were appropriate for preconsultation exchange, and 190 (46.0%) were inappropriate for preconsultation exchange. 167 (40.4%) referrals did not include enough information to determine appropriateness for preconsultation exchange. Most of these (83.8%) were made for hepatitis B or hepatitis C, despite the presence of explicit referral guidelines. Midlevel providers were more likely than physicians to provide enough information to determine appropriateness for preconsultation exchange. Conclusion In our urban healthcare system, preconsultation exchange appears to be an appropriate form of specialty care for some ambulatory hepatology consultations. Communication between primary care provider and specialist appears to be an important barrier to broader implementation of preconsultation exchange. Optimizing the preconsultation exchange is critical to improve the primary-specialty care interface, and to build a true Patient Centered Medical Home Neighborhood. PMID:23597797

  13. Development of an Ambulatory Clinical Pharmacy Prioritization Prediction Model for Patients With Diabetes.

    PubMed

    Lam, Simon W; Russo-Alvarez, Giavanna; Cristiani, Cari; Rothberg, Michael B

    2016-09-01

    Health care reform and the projected shortage of primary care physicians necessitate more efficient use of multidisciplinary collaboration. No studies, to date, have evaluated factors associated with treatment success among patients referred to a clinical pharmacist. To develop a prediction model using patient factors to assist in selecting patients with diabetes most likely to benefit from pharmacy interventions. A retrospective, nested case-control study was performed. A prediction model using multivariable logistic regression was developed, with model calibration and internal validation. Adult patients with diabetes who had a baseline hemoglobin A1C (A1C) ≥9%, who were consulted for collaborative pharmacy care between July 2009 and July 2014 were included. Success (cases) was defined as a decrease in A1C by 2% or a value of A1C <8% 1 year after the initial visit. Failures were those who did not achieve the A1C goal or were lost to follow-up. A total of 544 unique patients were included, with 243 (44.7%) classified as clinical successes and 301 as clinical failures. Independent factors associated with success included past medical history of cerebrovascular accident and higher baseline A1C, whereas use of short-acting insulin and higher number of classes of diabetic medications at baseline corresponded with failure. A prediction model for success using these factors had an optimism-adjusted C-statistics of 0.629, with good calibration. Referred patients with diabetes have baseline characteristics that are predictive of clinical success. A predictive model based on those factors performed well and might be utilized to improve pharmacist efficiency in the face of constrained resources. © The Author(s) 2016.

  14. Patient safety perspectives of providers and nurses: the experience of a rural ambulatory care practice using an EHR with E-prescribing.

    PubMed

    Bramble, James D; Abbott, Amy A; Fuji, Kevin T; Paschal, Karen A; Siracuse, Mark V; Galt, Kimberly

    2013-01-01

    The purpose of this study was to identify and describe safety improvements and concerns indicated by providers and nurses in a rural community ambulatory care practice using an electronic health record with an e-prescribing feature (EHR with eRx). Two focus groups were conducted; 1 with providers and the other with nurses. Participants responded to questions and discussed their perceptions of safety improvements and concerns with use of an EHR with eRx. Transcripts were analyzed using sequential and continuous analytic methods. Three themes centered on efficiency and patient safety emerged from data analysis: (1) EHR with eRx adoption has led to new improvements and concerns for patient safety, (2) the EHR with eRx has affected efficiency in the clinic, and (3) EHR with eRx adoption has led to workarounds. Concerns remain among providers and nurses regarding the use of EHR with eRx applications, although concerns differed between groups. Therefore, When EHR improvements are planned, it is important to consider the differing needs of the professionals who deliver care. © 2013 National Rural Health Association.

  15. Ambulatory Assessment.

    PubMed

    Carpenter, Ryan W; Wycoff, Andrea M; Trull, Timothy J

    2016-08-01

    In recent years, significant technological advances have changed our understanding of dynamic processes in clinical psychology. A particularly important agent of change has been ambulatory assessment (AA). AA is the assessment of individuals in their daily lives, combining the twin benefits of increased ecological validity and minimized retrospective biases. These benefits make AA particularly well-suited to the assessment of dynamic processes, and recent advancements in technology are providing exciting new opportunities to understand these processes in new ways. In the current article, we briefly detail the capabilities currently offered by smartphones and mobile physiological devices, as well as some of the practical and ethical challenges of incorporating these new technologies into AA research. We then provide several examples of recent innovative applications of AA methodology in clinical research, assessment, and intervention and provide a case example of AA data generated from a study utilizing multiple mobile devices. In this way, we aim to provide a sense of direction for researchers planning AA studies of their own.

  16. Consensus on Insulin Dose and Titration Algorithms in Ambulatory Care of Type 2 Diabetes in India.

    PubMed

    Kovil, Rajiv; Chawla, Manoj; Rajput, Rajesh; Singh, A K; Sinha, Binayak; Ghosal, Samit; Ballani, Piya; Gupta, Sunil; Tanna, Snehal; Bandukwala, S M; Shah, Tejas; Negalur, Vijay; Bhoraskar, Anil; Aravind, S R; Zargar, Abdul H; Kesavadev, Jothydev; Das, Ashok Kumar

    2017-02-01

    Insulin is the oldest of the currently available treatment options in Type 2 diabetes mellitus (T2DM) and is considered as the most effective glucose lowering agent. Despite this, decision on starting insulin therapy is often delayed in India as well as worldwide due to various barriers at both patient and physician levels. Appropriate insulin dosing and titration is also critical to the successful achievement of tight glycaemic control. To provide simple and easily implementable guidelines to primary care physicians on appropriate insulin dosing and titration of various insulin regimens for both initiation and intensification. Each insulin regimen (once daily [OD] basal, OD, twice daily and thrice daily premixed, basal-plus and basal-bolus) was presented and evaluated for dosing and titration based on established guidelines, data from approved pack inserts, and published scientific literature. These evaluations were then factored into the national context based on the expert committee representatives patient-physician experience in their clinical practice and common therapeutic practices followed in India. Recommendations for dosing and titration of basal, basal-plus, premixed and basal-bolus insulins were developed. The key recommendations are that insulin doses can be adjusted once or twice weekly; adjustment can be based on lowest/mean of three recent self-monitoring of plasma glucose pre-meal/fasting plasma glucose (FPG) values. The titration should be based on FPG or pre-meal value of 80-130 mg/dL and the dose should be reduced by 10-20% for patients reporting hypoglycaemia(<70mg/dL). The consensus based recommendations mentioned in this paper will be a useful reference tool for health care practitioners, to initiate, optimise and intensify insulin therapy and to successfully achieve optimal glucose control.

  17. Dare to excel in ambulatory surgery.

    PubMed

    Gruendemann, B J

    1985-02-01

    Outpatient surgery is not just an off-shoot or satellite of maturing inpatient care. It is a distinct entity and one nursing can use to full advantage. It is a superb clinical laboratory for nursing students who are studying perioperative nursing. Here, students can see all three phases of patient care in three to four hours. I chose the field of ambulatory surgery and found a new venture and a clinical area ready for creative ideas and new ways of implementing the nursing process. One characteristic of excellent companies, say Peters and Waterman, is the presence of champions. "The champion is not a blue-sky dreamer, or an intellectual giant. The champion might even be an idea thief. But, above all, he's the pragmatic one who grabs onto someone else's theoretical construct if necessary and bullheadedly pushes it to fruition." Are you a champion, and what will you do to make your ambulatory surgery center be known as the best?

  18. Incorporating patient-reported outcomes to improve emotional distress screening and assessment in an ambulatory oncology clinic.

    PubMed

    Chiang, Anne C; Buia Amport, Stephanie; Corjulo, Diane; Harvey, Katherine L; McCorkle, Ruth

    2015-05-01

    Assessment of distress and well-being of patients with cancer is not always documented or addressed in a clinical visit, reflecting a need for improved psychosocial screening. A multidisciplinary team completed process mapping for emotional distress assessment in two clinics. Barriers were identified through cause-and-effect analysis, and an intervention was chosen. Patient-reported outcomes were collected over 6 months using the validated National Comprehensive Cancer Network Emotional Distress Thermometer (EDT) paper tool. The American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) measures were compared before and after intervention. During 6 months, a total of 864 tools were collected from 1,344 patients in two ambulatory clinics (64%). Electronic medical record documentation of distress increased from 19.2% to 34% during the 6 months before and after intervention. QOPI measures showed an increase in emotional well-being documentation. Of 29 new and 835 return patients, 62% indicated mild distress (EDT, 0 to 3), 18% moderate (EDT, 4 to 6), and 11% severe (EDT, 7 to 10). The average distress score of new patients was significantly higher than that of return patients (5.39 [n = 26] v 2.52 [n = 754]; P < .001). The top problems for patients with moderate and severe distress were worry, fatigue, pain, and nervousness; depression and sadness were particularly noted in patients reporting severe distress. Eleven percent of patients were referred to the social worker on site. A pilot intervention collecting Patient-reported outcomes in two ambulatory clinics led to increase in psychosocial distress screening followed by sustained improvement, indicated by both process and QOPI measures. Copyright © 2015 by American Society of Clinical Oncology.

  19. Feasibility and diagnostic accuracy of the Patient-Reported Outcomes Measurement Information System (PROMIS) item banks for routine surveillance of sleep and fatigue problems in ambulatory cancer care.

    PubMed

    Leung, Yvonne W; Brown, Catherine; Cosio, Andrea Perez; Dobriyal, Aditi; Malik, Noor; Pat, Vivien; Irwin, Margaret; Tomasini, Pascale; Liu, Geoffrey; Howell, Doris

    2016-09-15

    Routine screening for problematic symptoms is emerging as a best practice in cancer systems globally. The objective of this observational study was to assess the feasibility and diagnostic accuracy of Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive testing (CAT) for fatigue and sleep-disturbance items compared with legacy measures in routine ambulatory cancer care. Patients who attended outpatient clinics at the Princess Margaret Cancer Center completed PROMIS CAT item banks and legacy measures (the Functional Assessment of Chronic Illness Therapy [FACIT]-Fatigue scale and the Insomnia Severity Index [ISI]) using tablet computers during clinic visits. The completion rates, patient acceptability, and diagnostic accuracy of PROMIS CAT were evaluated against legacy measures using receiver operating characteristic (ROC) curve analysis. Participants consisted of 336 patients (mean age ± standard deviation, 57.4 ± 15.7 years; 55% females; 75% Caucasian). Over 98% of patients did not find symptom screening was burdensome, although only 65% were willing to complete the survey at every visit. PROMIS CAT scores were significantly correlated with both FACIT-Fatigue scores (r = -0.83) and ISI scores (r = -0.57; p < 0.0001 for all). Areas under the curve (AUC) by ROC analysis for fatigue were 0.946 using the FACIT-Fatigue cutoff ≤30, 0.910 for sleep disturbance, and 0.922 for sleep impairment using the ISI cutoff ≥15. The recommended T-score cut-off for PROMIS CAT Fatigue was 57, Sleep Disturbance was 57, and Sleep Impairment was 57. The current results support the feasibility and accuracy of PROMIS CAT and its potential for use in routine ambulatory cancer care. Future research will assess feedback of these data to clinicians and evaluate effects on earlier identification of and intervention for these problems. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2906-2917. © 2016 American Cancer

  20. Benefits and obstacles of health status assessment in ambulatory settings. The clinician's point of view. The Dartmouth Primary Care COOP Project.

    PubMed

    Wasson, J; Keller, A; Rubenstein, L; Hays, R; Nelson, E; Johnson, D

    1992-05-01

    In the past decade physicians have identified the need to expand patient assessment to include global function and quality of life. During the same period, the busy clinic has evolved into the location where this assessment seems most appropriate. Integrating functional health assessment into a busy clinical practice is difficult because the necessary steps require time, thought, recording, and follow-up. Attention to the office ecosystem is very important before any patient care management method is introduced. The clinician must transform the results of health status screening into a specific functional diagnosis. The clinician has to understand the sensitivity, specificity, and predictive value of the measure for a preliminary diagnosis to be made. Often, additional measurements must be taken to establish a specific diagnosis. These steps encompass assessment linkage. Once the specific cause for the dysfunction is recognized, the clinician then has to determine the need for special resources. This is called the resource linkage. By following the steps outlined in this paper, the clinician should be able to overcome many obstacles for functional health status assessment in busy ambulatory settings.

  1. [Computerized ambulatory adolescent care--the experience of PAIA/ABEB].

    PubMed

    Andrade, H H; Marques, C M; Gouveia, M C; Gregório, Y M

    1996-01-01

    PAIA (Program for Adolescent Integral Assistance from ABEB) is one of the preventive medicine programs of the Employee Beneficent Association at Belgo Mineira Metallurgy Company. Since its implementation, in February 1992, it has been offering specific medical assistance and educational instruction to adolescents from 11 to 18 years old through informative group dynamics. Age and maturity level are the guidelines for group formation. The groups are supervised by a multidisciplinary team and the methodology is playful and participatory. The themes approached in the meetings are chosen according to the adolescents' interest and maturity. After two years, the program was completely computerized aiming at improving the quality of assistance and accelerating services. PAIA/ABEB Program has surpassed all expectations concerning adolescents' and parents' interest and participation and the adolescents have become extra sources of information about the program and health education in their community. Behavioral changes like more concern about health care and more search for dialogue with meaningful adults have been observed. The observations and research carried out with adolescents have become a guideline for the preventive medicine campaigns at the firms belonging to Belgo Mineira Group. Indeed, differentiated medical assistance and global approach towards adolescence have been created in the clinic centers.

  2. Limited Health Literacy is a Barrier to Medication Reconciliation in Ambulatory Care

    PubMed Central

    Persell, Stephen D.; Osborn, Chandra Y.; Richard, Robert; Skripkauskas, Silvia

    2007-01-01

    Background Limited health literacy may influence patients’ ability to identify medications taken; a serious concern for ambulatory safety and quality. Objective To assess the relationship between health literacy, patient recall of antihypertensive medications, and reconciliation between patient self-report and the medical record. Design In-person interviews, literacy assessment, medical records abstraction. Participants Adults with hypertension at three community health centers. Measurement We measured health literacy using the short-form Test of Functional Health Literacy in Adults. Patients were asked about the medications they took for blood pressure. Their responses were compared with the medical record. Results Of 119 participants, 37 (31%) had inadequate health literacy. Patients with inadequate health literacy were less able to name any of their antihypertensive medications compared to those with adequate health literacy (40.5% vs 68.3%, p = 0.005). After adjusting for age and income, this difference remained (adjusted odds ratio [OR] = 2.9, 95% confidence interval [95%CI] = 1.3–6.7). Agreement between patient reported medications and the medical record was low: 64.9% of patients with inadequate and 37.8% with adequate literacy had no medications common to both lists. Conclusions Limited health literacy was associated with a greater number of unreconciled medications. Future studies should investigate how this may impact safety and hypertension control. PMID:17786521

  3. Cost effectiveness, safety, and satisfaction with video telepsychiatry versus face-to-face care in ambulatory settings.

    PubMed

    Modai, Ilan; Jabarin, Mahmoud; Kurs, Rena; Barak, Peretz; Hanan, Ilan; Kitain, Ludmila

    2006-10-01

    Videoconference telepsychiatry provides an alternative for the psychiatric treatment of mental health patients who reside in remote communities. The objective of this study was to compare institutional ambulatory and hospitalization costs, treatment adherence, patient and physician satisfaction, and treatment safety between mental healthcare via videoconferencing and care provided in person. Data collected for 1 year of telepsychiatry treatment was compared to that of the preceding year and a matched comparison group. Twenty-nine patients from Or Akiva and 20 patients from Reut Hostel in Hadera who met the inclusion criteria agreed to participate; 24 and 15 patients, respectively, completed the study. Forty-two matched patients, who continued face-to-face interviews, comprised the comparison group. Drop-out patients and those who did not consent to telepsychiatry treatment were not involved. During the year of telepsychiatry treatment, patients and physicians were satisfied and treatment was safe. However, 1 hour of telepsychiatry treatment was more expensive than face-to-face care, and a tendency of increased hospitalizations was noted. Adherence ratios before and during telepsychiatry treatment were similar, but were twice as high versus the comparison group. The limited sample size precludes the drawing of definite conclusions, and further studies involving a larger study population and longer duration of investigation is warranted.

  4. The safety attitudes questionnaire - ambulatory version: psychometric properties of the Slovenian version for the out-of-hours primary care setting.

    PubMed

    Klemenc-Ketis, Zalika; Maletic, Matjaz; Stropnik, Vesna; Deilkås, Ellen Tveter; Hofoss, Dag; Bondevik, Gunnar Tschudi

    2017-01-13

    Several tools have been developed to measure safety attitudes of health care providers, out of which the Safety Attitudes Questionnaire (SAQ) is regarded as one of the most appropriate ones. In 2007, it was adapted to outpatient (primary health care) settings and in 2014 it was tested in out-of-hours health care settings in Norway. The purpose of this study was to translate the English version of the SAQ-Ambulatory Version (SAQ-AV) to Slovenian language; to test its reliability; and to explore its factor structure. This was a cross-sectional study that took place in Slovenian out-of-hours primary care clinics in March-May 2015 as a part of an international study entitled Patient Safety Culture in European Out-of-hours services. The questionnaire consisted of the Slovenian version of the SAQ-AV. The link to the questionnaire was emailed to health care workers in the out-of-hours clinics. A total of 438 participants were invited. We performed exploratory factor analysis. Out of 438 invited participants, 250 answered the questionnaire (response rate 57.1%). Exploratory factor analysis put forward five factors: 1) Perceptions of management, 2) Job satisfaction, 3) Safety climate, 4) Teamwork climate, and 5) Communication. Cronbach's alpha of the whole SAQ-AV was 0.922. Cronbach's alpha of the five factors ranged from 0.587 to 0.791. Mean total score of the SAQ-AV was 56.6 ± 16.0 points. The factor with the highest average score was Teamwork climate and the factor with the lowest average was Job satisfaction. Based on the results in our study, we cannot state that the SAQ-AV is a reliable tool for measuring safety culture in the Slovenian out-of-hours care setting. Our study also showed that there might be other safety culture factors in out-of-hours care not recognised before. We therefore recommend larger studies aiming to identify an alternative factor structure.

  5. Recommendations for Standardizing Glucose Reporting and Analysis to Optimize Clinical Decision Making in Diabetes: The Ambulatory Glucose Profile

    PubMed Central

    Bergenstal, Richard M.; Ahmann, Andrew J.; Bailey, Timothy; Beck, Roy W.; Bissen, Joan; Buckingham, Bruce; Deeb, Larry; Dolin, Robert H.; Garg, Satish K.; Goland, Robin; Hirsch, Irl B.; Klonoff, David C.; Kruger, Davida F.; Matfin, Glenn; Mazze, Roger S.; Olson, Beth A.; Parkin, Christopher; Peters, Anne; Powers, Margaret A.; Rodriguez, Henry; Southerland, Phil; Strock, Ellie S.; Tamborlane, William; Wesley, David M.

    2013-01-01

    Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes mellitus. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardizing the analysis and presentation of glucose monitoring data, with the initial focus on data derived from continuous glucose monitoring systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile, and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This article provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients. PMID:23567014

  6. Relationship Between Clinical Outcome Measures and Parent Proxy Reports of Health-related Quality of Life in Ambulatory Children with Duchenne Muscular Dystrophy

    PubMed Central

    McDonald, Craig M.; McDonald, Dawn A.; Bagley, Anita M.; Sienko-Thomas, Susan; Buckon, Cathleen; Henricson, Eric; Nicorici, Alina; Sussman, Michael D.

    2013-01-01

    In Duchenne muscular dystrophy, data directly linking changes in clinical outcome measures to patient-perceived well-being are lacking. Our study evaluated the relationship between clinical outcome measures used in clinical trials of ambulatory Duchenne muscular dystrophy (Vignos functional grade, quantitative knee extension strength, timed functional performance measures, and gait velocity) and 2 health-related quality of life measures — the PODCI and PedsQL™ — in 52 ambulatory Duchenne muscular dystrophy subjects and 36 controls. Those with the disease showed significant decrements in parent proxy-reported health-related quality of life measures versus controls across all domains. The PODCI transfers/basic mobility, PODCI sports/physical function, and PedsQL™ physical functioning domains had significant associations with age (and hence disease progression), and traditional clinical outcome measures employed in clinical trials of ambulatory boys with Duchenne muscular dystrophy. Selected domains of the PODCI and generic PedsQL™ are potential patient-reported outcome measures for clinical trials in ambulatory individuals with the disease. PMID:20558672

  7. Relationship between clinical outcome measures and parent proxy reports of health-related quality of life in ambulatory children with Duchenne muscular dystrophy.

    PubMed

    McDonald, Craig M; McDonald, Dawn A; Bagley, Anita; Sienko Thomas, Susan; Buckon, Cathleen E; Henricson, Eric; Nicorici, Alina; Sussman, Michael D

    2010-09-01

    In Duchenne muscular dystrophy, data directly linking changes in clinical outcome measures to patient-perceived well-being are lacking. This study evaluated the relationship between clinical outcome measures used in clinical trials of ambulatory Duchenne muscular dystrophy (Vignos functional grade, quantitative knee extension strength, timed functional performance measures, and gait velocity) and 2 health-related quality of life measures--the Pediatric Outcomes Data Collection Instrument and Pediatric Quality of Life Inventory-in 52 ambulatory Duchenne muscular dystrophy subjects and 36 controls. Those with the disease showed significant decrements in parent proxy-reported health-related quality of life measures versus controls across all domains. The Pediatric Outcomes Data Collection Instrument transfers/basic mobility and sports/ physical function and the Pediatric Quality of Life Inventory physical functioning domains had significant associations with age (and hence disease progression) and traditional clinical outcome measures employed in clinical trials of ambulatory boys with Duchenne muscular dystrophy. Selected domains of the Pediatric Outcomes Data Collection Instrument and generic Pediatric Quality of Life Inventory are potential patient-reported outcome measures for clinical trials in ambulatory individuals with the disease.

  8. Effects of continuous positive airway pressure treatment on clinic and ambulatory blood pressures in patients with obstructive sleep apnea and resistant hypertension: a randomized controlled trial.

    PubMed

    Muxfeldt, Elizabeth S; Margallo, Victor; Costa, Leonardo M S; Guimarães, Gleison; Cavalcante, Aline H; Azevedo, João C M; de Souza, Fabio; Cardoso, Claudia R L; Salles, Gil F

    2015-04-01

    The effect of continuous positive airway pressure (CPAP) on blood pressures (BPs) in patients with resistant hypertension and obstructive sleep apnea is not established. We aimed to evaluate it in a randomized controlled clinical trial, with blinded assessment of outcomes. Four hundred thirty-four resistant hypertensive patients were screened and 117 patients with moderate/severe obstructive sleep apnea, defined by an apnea-hypopnea index ≥15 per hour, were randomized to 6-month CPAP treatment (57 patients) or no therapy (60 patients), while maintaining antihypertensive treatment. Clinic and 24-hour ambulatory BPs were obtained before and after 6-month treatment. Primary outcomes were changes in clinic and ambulatory BPs and in nocturnal BP fall patterns. Intention-to-treat and per-protocol (limited to those with uncontrolled ambulatory BPs) analyses were performed. Patients had mean (SD) 24-hour BP of 129(16)/75(12) mm Hg, and 59% had uncontrolled ambulatory BPs. Mean apnea-hypopnea index was 41 per hour and 58.5% had severe obstructive sleep apnea. On intention-to-treat analysis, there was no significant difference in any BP change, neither in nocturnal BP fall, between CPAP and control groups. The best effect of CPAP was on night-time systolic blood pressure in per-protocol analysis, with greater reduction of 4.7 mm Hg (95% confidence interval, -11.3 to +3.1 mm Hg; P=0.24) and an increase in nocturnal BP fall of 2.2% (95% confidence interval, -1.6% to +5.8%; P=0.25), in comparison with control group. In conclusion, CPAP treatment had no significant effect on clinic and ambulatory BPs in patients with resistant hypertension and moderate/severe obstructive sleep apnea, although a beneficial effect on night-time systolic blood pressure and on nocturnal BP fall might exist in patients with uncontrolled ambulatory BP levels. © 2015 American Heart Association, Inc.

  9. The effectiveness of therapeutic patient education on adherence to oral anti-cancer medicines in adult cancer patients in ambulatory care settings: a systematic review.

    PubMed

    Arthurs, Gilly; Simpson, Janice; Brown, Andrea; Kyaw, Ohnma; Shyrier, Sharon; Concert, Catherine M

    2015-06-12

    . There is a paucity of research evidence on the effectiveness of therapeutic patient educational interventions for improving patient adherence to oral cancer medicines. The effect of therapeutic patient educational interventions on oral anti-cancer medicine adherence has yet to be determined. Therapeutic patient educational interventions remain questionable, differing in format and educational strategies. A specific standardized methodology and evaluation approach to therapeutic patient education may reduce symptomatology, prevent side effects, maximize health outcomes and positively affect the quality of life and survival of adult patients with cancer. There is limited evidence that therapeutic patient educational interventions improve oral anti-cancer medicine adherence in adult patients with cancer in ambulatory care settings. A growing number of patients with cancer are being prescribed oral anti-cancer medicines; a better understanding of how therapeutic patient education strategies are effectively implemented may promote patient self-motivation and oral anti-cancer medicine adherence. This review recommends the development of a specific standardized methodology and evaluation approach to therapeutic patient education that may empower patients to increase their adherence to self-managed medication and achieve positive health outcomes Clinical trials with larger sample sizes, standardization of content, comparing specific adherence education or tailored education interventions are needed. The Joanna Briggs Institute.

  10. Electronic Clinical Surveillance to Improve Outpatient Care: Diverse Applications within an Integrated Delivery System.

    PubMed

    Danforth, Kim N; Smith, Andrea E; Loo, Ronald K; Jacobsen, Steven J; Mittman, Brian S; Kanter, Michael H

    2014-01-01

    Efforts to improve patient safety have largely focused on inpatient or emergency settings, but the importance of patient safety in ambulatory care is increasingly being recognized as a key component of overall health care quality. Care gaps in outpatient settings may include missed diagnoses, medication errors, or insufficient monitoring of patients with chronic conditions or on certain medications. Further, care gaps may occur across a wide range of clinical conditions. We report here an innovative approach to improve patient safety in ambulatory settings - the Kaiser Permanente Southern California (KPSC) Outpatient Safety Net Program - which leverages electronic health information to efficiently identify and address a variety of potential care gaps across different clinical conditions. Between 2006 and 2012, the KPSC Outpatient Safety Net Program implemented 24 distinct electronic clinical surveillance programs, which routinely scan the electronic health record to identify patients with a particular condition or event. For example, electronic clinical surveillance may be used to scan for harmful medication interactions or potentially missed diagnoses (e.g., abnormal test results without evidence of subsequent care). Keys to the success of the program include strong leadership support, a proactive clinical culture, the blame-free nature of the program, and the availability of electronic health information. The Outpatient Safety Net Program framework may be adopted by other organizations, including those who have electronic health information but not an electronic health record. In the future, the creation of a forum to share electronic clinical surveillance programs across organizations may facilitate more rapid improvements in outpatient safety.

  11. Same organization, same electronic health records (EHRs) system, different use: exploring the linkage between practice member communication patterns and EHR use patterns in an ambulatory care setting

    PubMed Central

    Leykum, Luci K; McDaniel, Reuben R

    2011-01-01

    Objective Despite efforts made by ambulatory care organizations to standardize the use of electronic health records (EHRs), practices often incorporate these systems into their work differently from each other. One potential factor contributing to these differences is within-practice communication patterns. The authors explore the linkage between within-practice communication patterns and practice-level EHR use patterns. Design Qualitative study of six practices operating within the same multi-specialty ambulatory care organization using the same EHR system. Semistructured interviews and direct observation were conducted with all physicians, nurses, medical assistants, practice managers, and non-clinical staff from each practice. Measurements An existing model of practice relationships was used to analyze communication patterns within the practices. Practice-level EHR use was defined and analyzed