Defining and evaluating quality for ambulatory care educational programs.

PubMed

Bowen, J L; Stearns, J A; Dohner, C; Blackman, J; Simpson, D

1997-06-01

As the training of medical students and residents increasingly moves to ambulatory care settings, clerkship and program directors must find a way to use their limited resources to guide the development and evaluation of the quality of these ambulatory-based learning experiences. To evaluate quality, directors must first define, in operational and measurable terms, what is meant by the term "quality" as it is applied to ambulatory-based education. Using educational theories and the definition of quality used by health care systems, the authors propose an operational definition of quality for guiding the planning, implementation, and evaluation of ambulatory care educational programs. They assert that quality is achieved through the interaction of an optimal learning environment, defined educational goals and positive outcomes, participant satisfaction, and cost-effectiveness. By describing the components of quality along with examples of measurable indicators, the authors provide a foundation for the evaluation and improvement of instructional innovations in ambulatory care education for the benefit of teachers, learners, and patients.

Ambulatory blood pressure and cardiovascular events in chronic kidney disease

PubMed Central

Agarwal, Rajiv

2007-01-01

Purpose of review Hypertension is an important risk factor for adverse cardiovascular and renal outcomes particularly in patients with chronic kidney disease. This review compares blood pressure measurements obtained in the clinic with those obtained outside the clinic to predict cardiovascular and renal injury and outcomes. Recent findings Data are accumulating that suggest that ambulatory blood pressure monitoring is a superior prognostic marker compared to blood pressures obtained in the clinic. Use of ambulatory blood pressure monitoring can detect white coat hypertension and masked hypertension which results in less misclassification of blood pressures. Ambulatory blood pressure monitoring is a marker of cardiovascular end points in CKD. Non dipping is associated with proteinuria and lower GFR. Although non-dipping is associated with more ESRD and cardiovascular events, adjustment for other risk factors removes the prognostic significance of non-dipping. For patients with CKD, not on dialysis, 24 hour ambulatory BP of <125/75 mm Hg, daytime ambulatory of <130/85 mm Hg and nighttime ambulatory BP of <110/70 mm Hg appear to be reasonable goal BP targets. In the management of hypertension in patients with CKD, control of hypertension is important. Ambulatory BP monitoring may be useful to assign more aggressive treatment to patients with masked hypertension and withdraw antihypertensive therapy in patients with white-coat hypertension. Summary Ambulatory blood pressure monitoring can refine cardiovascular and renal risk assessment in all stages of chronic kidney disease. The independent prognostic role of non-dipping is unclear. PMID:17868791

Hospital-based, acute care after ambulatory surgery center discharge.

PubMed

Fox, Justin P; Vashi, Anita A; Ross, Joseph S; Gross, Cary P

2014-05-01

As a measure of quality, ambulatory surgery centers have begun reporting rates of hospital transfer at discharge. This process, however, may underestimate the acute care needs of patients after care. We conducted this study to determine rates and evaluate variation in hospital transfer and hospital-based, acute care within 7 days among patients discharged from ambulatory surgery centers. Using data from the Healthcare Cost and Utilization Project, we identified adult patients who underwent a medical or operative procedure between July 2008 and September 2009 at ambulatory surgery centers in California, Florida, and Nebraska. The primary outcomes were hospital transfer at the time of discharge and hospital-based, acute care (emergency department visits or hospital admissions) within 7-days expressed as the rate per 1,000 discharges. At the ambulatory surgery center level, rates were adjusted for age, sex, and procedure-mix. We studied 3,821,670 patients treated at 1,295 ambulatory surgery centers. At discharge, the hospital transfer rate was 1.1 per 1,000 discharges (95% confidence interval 1.1-1.1). Among patients discharged home, the hospital-based, acute care rate was 31.8 per 1,000 discharges (95% confidence interval 31.6-32.0). Across ambulatory surgery centers, there was little variation in adjusted hospital transfer rates (median = 1.0/1,000 discharges [25th-75th percentile = 1.0-2.0]), whereas substantial variation existed in adjusted, hospital-based, acute care rates (28.0/1,000 [21.0-39.0]). Among adult patients undergoing ambulatory care at surgery centers, hospital transfer at time of discharge from the ambulatory care center is a rare event. In contrast, the rate of need for hospital-based, acute care in the first week afterwards is nearly 30-fold greater, varies across centers, and may be a more meaningful measure for discriminating quality. Published by Mosby, Inc.

[Ambulatory pediatric surgery: 25 years of experience].

PubMed

González Landa, G; Sánchez-Ruiz, I; Prado, C; Azcona, I; Sánchez, C

2000-10-01

The objectives of this study are: collect 25 years of experience with ambulatory pediatric surgery in The Pediatric Surgery Service of Hospital de Cruces, present the results of a parents-patient satisfaction survey and show the estimated money savings in the last five years. In the period 1973-1997, 19,934 children (56% of the total surgical cases) were operated with ambulatory surgery, and have been grouped in five quinquenia, showing a constant increase of the percentage of ambulatory surgery. General surgery and ENT are the specialities that more frequently uses this type of surgery (72.4% and 68.6% of the surgical cases of each speciality, respectively, in the last ten years). In general surgery inguinal hernia is the most frequent diagnosis with an increase of orchidopexy in the last five years. ENT is doing ambulatory tonsilectomies in the last ten years. The prolonged recovery stay and unanticipated admissions are rare, usually due to vomiting. The parents satisfaction survey shows great acceptancy, although 13% preferred an overnight postoperative stay. The estimated money saved in the last quinquenia has been important.

Effect of intensive versus standard clinic-based hypertension management on ambulatory blood pressure – results from the SPRINT ambulatory blood pressure study

PubMed Central

Drawz, Paul; 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

2016-01-01

The effect of clinic-based intensive hypertension treatment on ambulatory blood pressure (BP) is unknown. The goal of the Systolic Blood Pressure Intervention Trial (SPRINT) 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 mmHg (95% CI: 14.1 to 17.8 mmHg)), nighttime systolic BP (mean difference = 9.6 mmHg (95% CI: 7.7 to 11.5 mmHg)), daytime systolic BP (mean difference = 12.3 mmHg (95% CI: 10.6 to 13.9 mmHg)), and 24 hour systolic BP (mean difference = 11.2 mmHg (95% CI: 9.7 to 12.8 mmHg)). 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 less than 120 mmHg, as compared with less than 140 mmHg, 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. PMID:27849563

Challenges of ambulatory physiological sensing.

PubMed

Healey, Jennifer

2004-01-01

Applications for ambulatory monitoring span the spectrum from fitness optimization to cardiac defibrillation. This range of applications is associated with a corresponding range of required detection accuracies and a range of inconvenience and discomfort that wearers are willing to tolerate. This paper describes a selection of physiological sensors and how they might best be worn in the unconstrained ambulatory environment to provide the most robust measurements and the greatest comfort to the wearer. Using wireless mobile computing devices, it will be possible to record, analyze and respond to changes in the wearers' physiological signals in real time using these sensors.

Ambulatory measurement of ankle kinetics for clinical applications.

PubMed

Rouhani, H; Favre, J; Crevoisier, X; Aminian, K

2011-10-13

This study aimed to design and validate the measurement of ankle kinetics (force, moment, and power) during consecutive gait cycles and in the field using an ambulatory system. An ambulatory system consisting of plantar pressure insole and inertial sensors (3D gyroscopes and 3D accelerometers) on foot and shank was used. To test this system, 12 patients and 10 healthy elderly subjects wore shoes embedding this system and walked many times across a gait lab including a force-plate surrounded by seven cameras considered as the reference system. Then, the participants walked two 50-meter trials where only the ambulatory system was used. Ankle force components and sagittal moment of ankle measured by ambulatory system showed correlation coefficient (R) and normalized RMS error (NRMSE) of more than 0.94 and less than 13% in comparison with the references system for both patients and healthy subjects. Transverse moment of ankle and ankle power showed R>0.85 and NRMSE<23%. These parameters also showed high repeatability (CMC>0.7). In contrast, the ankle coronal moment of ankle demonstrated high error and lower repeatability. Except for ankle coronal moment, the kinetic features obtained by the ambulatory system could distinguish the patients with ankle osteoarthritis from healthy subjects when measured in 50-meter trials. The proposed ambulatory system can be easily accessible in most clinics and could assess main ankle kinetics quantities with acceptable error and repeatability for clinical evaluations. This system is therefore suggested for field measurement in clinical applications. Copyright © 2011 Elsevier Ltd. All rights reserved.

Prevalência de tromboembolismo pulmonar incidental em pacientes oncológicos: análise retrospectiva em grande centro

PubMed Central

Carneiro, Renata Mota; van Bellen, Bonno; Santana, Pablo Rydz Pinheiro; Gomes, Antônio Carlos Portugal

2017-01-01

Resumo Contexto Devido à maior aplicação de exames de imagem rotineiros, especialmente nos pacientes com neoplasia para controle da doença, vem aumentando o diagnóstico de tromboembolismo pulmonar (TEP) incidental, importante fator de morbimortalidade associado. Objetivo Identificar os casos de TEP incidental em pacientes oncológicos submetidos a tomografia computadorizada (TC) de tórax, correlacionando aspectos clínicos e fatores de risco associados. Métodos Estudo retrospectivo de todos os episódios de TEP ocorridos de janeiro de 2013 a junho de 2016, com seleção dos pacientes oncológicos e divisão deles em dois grupos: com suspeita clínica e sem suspeita clínica (incidentais) de embolia pulmonar. Resultados Foram avaliados 468 pacientes com TEP no período citado. Destes, 23,1% eram oncológicos, entre os quais 44,4% apresentaram achado incidental de embolia pulmonar na TC de tórax. Não houve diferença estatística entre os grupos para sexo, idade e tabagismo. Quanto à procedência, 58,3% dos pacientes sem suspeita clínica eram de origem ambulatorial e 41,7% com suspeita de TEP vinham do pronto-socorro (p < 0,001). As neoplasias mais prevalentes foram de pulmão (17,6%), intestino (15,7%) e mama (13,0%). Aqueles com achado incidental apresentaram significativamente mais metástases, sem diferença entre os grupos para realização de quimioterapia, radioterapia ou cirurgia recente. Quanto aos sintomas apresentados, 41,9% daqueles sem suspeita clínica tinham queixas sugestivas de TEP quando realizaram o exame. Conclusão TEP incidental é frequente em pacientes oncológicos, especialmente naqueles provenientes de seguimento ambulatorial e em estágios avançados da doença. Sintomas sugestivos de TEP estavam presentes em pacientes sem suspeita clínica ao realizarem a TC de tórax. PMID:29930652

Development of Quality Metrics in Ambulatory Pediatric Cardiology.

PubMed

Chowdhury, Devyani; Gurvitz, Michelle; Marelli, Ariane; Anderson, Jeffrey; Baker-Smith, Carissa; Diab, Karim A; Edwards, Thomas C; Hougen, Tom; Jedeikin, Roy; Johnson, Jonathan N; Karpawich, Peter; Lai, Wyman; Lu, Jimmy C; Mitchell, Stephanie; Newburger, Jane W; Penny, Daniel J; Portman, Michael A; Satou, Gary; Teitel, David; Villafane, Juan; Williams, Roberta; Jenkins, Kathy

2017-02-07

The American College of Cardiology Adult Congenital and Pediatric Cardiology (ACPC) Section had attempted to create quality metrics (QM) for ambulatory pediatric practice, but limited evidence made the process difficult. The ACPC sought to develop QMs for ambulatory pediatric cardiology practice. Five areas of interest were identified, and QMs were developed in a 2-step review process. In the first step, an expert panel, using the modified RAND-UCLA methodology, rated each QM for feasibility and validity. The second step sought input from ACPC Section members; final approval was by a vote of the ACPC Council. Work groups proposed a total of 44 QMs. Thirty-one metrics passed the RAND process and, after the open comment period, the ACPC council approved 18 metrics. The project resulted in successful development of QMs in ambulatory pediatric cardiology for a range of ambulatory domains. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Prescription Drug Shortages: Implications for Ambulatory Pediatrics.

PubMed

Donnelly, Katie A; Zocchi, Mark S; Katy, Tamara A; Fox, Erin R; van den Anker, John N; Mazer-Amirshahi, Maryann E

2018-05-08

To describe contemporary drug shortages affecting general ambulatory pediatrics. Data from January 2001 to December 2015 were obtained from the University of Utah Drug Information Service. Two pediatricians reviewed drug shortages and identified agents used in ambulatory pediatrics. Shortage data were analyzed by the type of drug, formulation, reason for shortage, duration, marketing status, if a pediatric friendly-formulation was available, or if it was a single-source product. The availability of an alternative, and whether that alternative was affected by a shortage, also was noted. Of 1883 products in shortage during the study period, 314 were determined to be used in ambulatory pediatrics. The annual number of new pediatric shortages decreased initially but then increased to a high of 38 in 2011. Of the 314 pediatric shortages, 3.8% were unresolved at the end of the study. The median duration of resolved shortages was 7.6 months. The longest shortage was for ciprofloxacin 500-mg tablets. The most common class involved was infectious disease drugs. Pediatric-friendly dosage forms were affected in 19.1% of shortages. An alternative agent was available for 86% drugs; however, 29% of these also were affected. The most common reason for shortage was manufacturing problems. Drug shortages affected a substantial number of agents used in general ambulatory pediatrics. Shortages for single-source products are a concern if a suitable alternative is unavailable. Providers working in the ambulatory setting must be aware of current shortages and implement mitigation strategies to optimize patient care. Copyright © 2018 Elsevier Inc. All rights reserved.

Ambulatory surgery in orthopedics: experience of over 10,000 patients.

PubMed

Martín-Ferrero, M A; Faour-Martín, O; Simon-Perez, C; Pérez-Herrero, M; de Pedro-Moro, J A

2014-03-01

The concept of day surgery is becoming an increasingly important part of elective surgery worldwide. Relentless pressure to cut costs may constrain clinical judgment regarding the most appropriate location for a patient's surgical care. The aim of this study was to determine clinical and quality indicators relating to our experience in orthopedic day durgery, mainly in relation to unplanned overnight admission and readmission rates. Additionally, we focused on describing the main characteristics of the patients that experienced complications, and compared the patient satisfaction rates following ambulatory and non-ambulatory procedures. We evaluated 10,032 patients who underwent surgical orthopedic procedures according to the protocols of our Ambulatory Surgery Unit. All complications that occurred were noted. A quality-of-life assessment (SF-36 test) was carried out both pre- and postoperatively. Ambulatory substitution rates and quality indicators for orthopedic procedures were also determined. The major complication rate was minimal, with no mortal cases, and there was a high rate of ambulatory substitution for the procedures studied. Outcomes of the SF-36 questionnaire showed significant improvement postoperatively. An unplanned overnight admission rate of 0.14 % was achieved. Our institution has shown that it is possible to provide good-quality ambulatory orthopedic surgery. There still appears to be the potential to increase the proportion of these procedures. Surgeons and anesthesiologists must strongly adhere to strict patient selection criteria for ambulatory orthopedic surgery in order to reduce complications in the immediate postoperative term.

Reproducibility of blood pressure variation in older ambulatory and bedridden subjects.

PubMed

Tsuchihashi, Takuya; Kawakami, Yasunobu; Imamura, Tsuyoshi; Abe, Isao

2002-06-01

We investigated the influence of ambulation on the reproducibility of circadian blood pressure variation in older nursing home residents. Ambulatory blood pressure monitoring was performed twice in 37 older nursing home residents. Nursing home in Japan. Subjects included 18 ambulatory nursing home residents who had no limitation on physical activity and 19 bedridden residents who did not participate in physical activity. Twenty-four-hour, daytime, and nighttime blood pressure levels and their variability. The 24-hour and daytime variability of systolic blood pressure (SBP) was significantly greater in ambulatory than in bedridden subjects, whereas nighttime variability was similar. Significant correlations in SBP averaged for the whole day, daytime, and nighttime were observed between the two examinations in ambulatory (r =.80-.83) and bedridden (r =.83-.91) subjects, but the variabilities of SBP for the whole day and during the daytime of the first measurement were correlated with those of the second measurement in bedridden (r =.67 and r =.47, respectively) but not in ambulatory (r =.39 and r =.28, respectively) subjects. Significant correlations were found between the nocturnal SBP changes at two occasions in both ambulatory (r =.50) and bedridden (r =.51) subjects, but the dipper versus nondipper profiles, defined as reduction in SBP of greater than 10% versus not, showed low reproducibility in ambulatory subjects; five ambulatory (28%) and one bedridden (5%) subjects showed divergent profiles between the two examinations. The reproducibility of blood pressure variation in nursing home residents is influenced by ambulation.

Military Health Service System Ambulatory Work Unit (AWU).

DTIC Science & Technology

1988-04-01

E-40 BBC-4 Ambulatory Work Unit Distribution Screen Passes BBC - Neurosurgery Clinic .... ............. . E-40 BBD -I Initial Record...Screen Failures BBD - Ophthalmology Clinic ... ............ E-41 BBD -2 Distribution Screen Failures BBD - Ophthalmology Clinic ............ E-41 BBD -3...Descriptive Statistics Distribution Screen Passes BBD - Ophthalmology Clinic ............ E-42 BBD -4 Ambulatory Work Unit Distribution Screen Passes BBD

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

Competency-based learning in an ambulatory care setting: Implementation of simulation training in the Ambulatory Care Rotation during the final year of the MaReCuM model curriculum.

PubMed

Dusch, Martin; Narciß, Elisabeth; Strohmer, Renate; Schüttpelz-Brauns, Katrin

2018-01-01

Aim: As part of the MaReCuM model curriculum at Medical Faculty Mannheim Heidelberg University, a final year rotation in ambulatory care was implemented and augmented to include ambulatory care simulation. In this paper we describe this ambulatory care simulation, the designated competency-based learning objectives, and evaluate the educational effect of the ambulatory care simulation training. Method: Seventy-five final year medical students participated in the survey (response rate: 83%). The control group completed the ambulatory rotation prior to the implementation of the ambulatory care simulation. The experimental group was required to participate in the simulation at the beginning of the final year rotation in ambulatory care. A survey of both groups was conducted at the beginning and at the end of the rotation. The learning objectives were taken from the National Competency-based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM). Results: The ambulatory care simulation had no measurable influence on students' subjectively perceived learning progress, the evaluation of the ambulatory care rotation, or working in an ambulatory care setting. At the end of the rotation participants in both groups reported having gained better insight into treating outpatients. At the beginning of the rotation members of both groups assessed their competencies to be at the same level. The simulated ambulatory scenarios were evaluated by the participating students as being well structured and easy to understand. The scenarios successfully created a sense of time pressure for those confronted with them. The ability to correctly fill out a narcotic prescription form as required was rated significantly higher by those who participated in the simulation. Participation in the ambulatory care simulation had no effect on the other competencies covered by the survey. Discussion: The effect of the four instructional units comprising the ambulatory care simulation

Differentiation of lower urinary tract dysfunctions: The role of ambulatory urodynamic monitoring.

PubMed

Rademakers, Kevin L J; Drossaerts, Jamie M A F L; Rahnama'i, Mohammad S; van Koeveringe, Gommert A

2015-05-01

To determine the value of ambulatory urodynamic monitoring in the assessment of patients with lower urinary tract symptoms. This was a cross-sectional study including patients who underwent both conventional urodynamic and ambulatory urodynamic assessment at our Center between December 2002 and February 2013. The ambulatory urodynamic studies were interpreted in a standardized way by a resident experienced with urodynamic measurements, and one staff member who specialized in incontinence and urodynamics. A total of 239 patients (71 male and 168 female) were included in the present study. The largest subgroup of patients, 79 (33%), underwent ambulatory urodynamic monitoring based on suspicion of an acontractile bladder. However, 66 of these patients (83.5%) still showed contractions on ambulatory urodynamics. Other groups that were analyzed were patients with suspected storage dysfunction (47 patients), inconclusive conventional urodynamic studies (68 patients) and incontinence of unclear origin (45 patients). Particularly in this last group, ambulatory urodynamics appeared to be useful for discrimination between different causes of incontinence. Ambulatory urodynamic monitoring is a valuable discriminating diagnostic tool in patients with lower urinary tract symptoms who have already undergone conventional urodynamics, particularly in the case of patients with suspected bladder acontractility and incontinence of unclear origin during ambulatory urodynamics. Further study is required to determine the clinical implications of the findings and their relationship with treatment outcome. © 2015 The Japanese Urological Association.

Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality.

PubMed

Banegas, José R; Ruilope, Luis M; de la Sierra, Alejandro; Vinyoles, Ernest; Gorostidi, Manuel; de la Cruz, Juan J; Ruiz-Hurtado, Gema; Segura, Julián; Rodríguez-Artalejo, Fernando; Williams, Bryan

2018-04-19

Evidence for the influence of ambulatory blood pressure on prognosis derives mainly from population-based studies and a few relatively small clinical investigations. This study examined the associations of blood pressure measured in the clinic (clinic blood pressure) and 24-hour ambulatory blood pressure with all-cause and cardiovascular mortality in a large cohort of patients in primary care. We analyzed data from a registry-based, multicenter, national cohort that included 63,910 adults recruited from 2004 through 2014 in Spain. Clinic and 24-hour ambulatory blood-pressure data were examined in the following categories: sustained hypertension (elevated clinic and elevated 24-hour ambulatory blood pressure), "white-coat" hypertension (elevated clinic and normal 24-hour ambulatory blood pressure), masked hypertension (normal clinic and elevated 24-hour ambulatory blood pressure), and normotension (normal clinic and normal 24-hour ambulatory blood pressure). Analyses were conducted with Cox regression models, adjusted for clinic and 24-hour ambulatory blood pressures and for confounders. During a median follow-up of 4.7 years, 3808 patients died from any cause, and 1295 of these patients died from cardiovascular causes. In a model that included both 24-hour and clinic measurements, 24-hour systolic pressure was more strongly associated with all-cause mortality (hazard ratio, 1.58 per 1-SD increase in pressure; 95% confidence interval [CI], 1.56 to 1.60, after adjustment for clinic blood pressure) than the clinic systolic pressure (hazard ratio, 1.02; 95% CI, 1.00 to 1.04, after adjustment for 24-hour blood pressure). Corresponding hazard ratios per 1-SD increase in pressure were 1.55 (95% CI, 1.53 to 1.57, after adjustment for clinic and daytime blood pressures) for nighttime ambulatory systolic pressure and 1.54 (95% CI, 1.52 to 1.56, after adjustment for clinic and nighttime blood pressures) for daytime ambulatory systolic pressure. These relationships were

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

PubMed

Roski, J; Gregory, R

2001-12-01

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

Surgical Site Infections Following Pediatric Ambulatory Surgery: An Epidemiologic Analysis.

PubMed

Rinke, Michael L; Jan, Dominique; Nassim, Janelle; Choi, Jaeun; Choi, Steven J

2016-08-01

OBJECTIVE To identify surgical site infection (SSI) rates following pediatric ambulatory surgery, SSI outcomes and risk factors, and sensitivity and specificity of SSI administrative billing codes. DESIGN Retrospective chart review of pediatric ambulatory surgeries with International Classification of Disease, Ninth Revision (ICD-9) codes for SSI, and a systematic random sampling of 5% of surgeries without SSI ICD-9 codes, all adjudicated for SSI on the basis of an ambulatory-adapted National Healthcare Safety Network definition. SETTING Urban pediatric tertiary care center April 1, 2009-March 31, 2014. METHODS SSI rates and sensitivity and specificity of ICD-9 codes were estimated using sampling design, and risk factors were analyzed in case-rest of cohort, and case-control, designs. RESULTS In 15,448 pediatric ambulatory surgeries, 34 patients had ICD-9 codes for SSI and 25 met the adapted National Healthcare Safety Network criteria. One additional SSI was identified with systematic random sampling. The SSI rate following pediatric ambulatory surgery was 2.9 per 1,000 surgeries (95% CI, 1.2-6.9). Otolaryngology surgeries demonstrated significantly lower SSI rates compared with endocrine (P=.001), integumentary (P=.001), male genital (P<.0001), and respiratory (P=.01) surgeries. Almost half of patients with an SSI were admitted, 88% received antibiotics, and 15% returned to the operating room. No risk factors were associated with SSI. The sensitivity of ICD-9 codes for SSI following ambulatory surgery was 55.31% (95% CI, 12.69%-91.33%) and specificity was 99.94% (99.89%-99.97%). CONCLUSIONS SSI following pediatric ambulatory surgery occurs at an appreciable rate and conveys morbidity on children. Infect Control Hosp Epidemiol 2016;37:931-938.

Relationship of Office and Ambulatory Blood Pressure With Left Ventricular Global Longitudinal Strain.

PubMed

Sera, Fusako; Jin, Zhezhen; Russo, Cesare; Lee, Edward S; Schwartz, Joseph E; Rundek, Tatjana; Elkind, Mitchell S V; Homma, Shunichi; Sacco, Ralph L; Di Tullio, Marco R

2016-11-01

Left ventricular (LV) global longitudinal strain (GLS) is an early indicator of subclinical cardiac dysfunction, even when LV ejection fraction (LVEF) is normal, and is an independent predictor of cardiovascular events. Ambulatory blood pressure (BP) is a better predictor of cardiovascular events, including heart failure, than office BP. We investigated the association of office and ambulatory BP measurements with subclinical LV systolic dysfunction in a community-based cohort with normal LVEF. Two-dimensional speckle-tracking echocardiography and 24-hour ambulatory BP monitoring were performed in 577 participants (mean age 70±9 years; 60% women) with LVEF ≥50% from the Cardiovascular Abnormalities and Brain Lesions (CABL) study. Univariable and multivariable linear regression analyses were used to assess the associations of BP measures with GLS. Higher ambulatory and office BP values were consistently associated with impaired GLS. After adjustment for pertinent covariates (age, sex, race/ethnicity, body mass index, diabetes mellitus, coronary artery disease, LV mass index, and antihypertensive medication), office diastolic BP and ambulatory systolic and diastolic BPs (24-hour, daytime and nighttime) were independently associated with GLS (P = 0.003 for office DBP, P ≤ 0.001 for all ambulatory BPs). When ambulatory and office BP values were included in the same model, all ambulatory BP measures remained significantly associated with GLS (all P < 0.01), whereas office BP values were not. Ambulatory BP values are significantly associated with impaired GLS and the association is stronger than for office BP. Ambulatory BP monitoring might have a role in the risk stratification of hypertensive patients for early LV dysfunction.

Alternative approaches to ambulatory training: internal medicine residents' and program directors' perspectives.

PubMed

Thomas, Kris G; West, Colin P; Popkave, Carol; Bellini, Lisa M; Weinberger, Steven E; Kolars, Joseph C; Kogan, Jennifer R

2009-08-01

Internal medicine ambulatory training redesign, including recommendations to increase ambulatory training, is a focus of national discussion. Residents' and program directors' perceptions about ambulatory training models are unknown. To describe internal medicine residents' and program directors' perceptions regarding ambulatory training duration, alternative ambulatory training models, and factors important for ambulatory education. National cohort study. Internal medicine residents (N = 14,941) and program directors (N = 222) who completed the 2007 Internal Medicine In-Training Examination (IM-ITE) Residents Questionnaire or Program Directors Survey, representing 389 US residency programs. A total of 58.4% of program directors and 43.7% of residents preferred one-third or more training time in outpatient settings. Resident preferences for one-third or more outpatient training increased with higher levels of training (48.3% PGY3), female sex (52.7%), primary care program enrollment (64.8%), and anticipated outpatient-focused career, such as geriatrics. Most program directors (77.3%) and residents (58.4%) preferred training models containing weekly clinic. Although residents and program directors reported problems with competing inpatient-outpatient responsibilities (74.9% and 88.1%, respectively) and felt that absence of conflict with inpatient responsibilities is important for good outpatient training (69.4% and 74.2%, respectively), only 41.6% of residents and 22.7% of program directors supported models eliminating ambulatory sessions during inpatient rotations. Residents' and program directors' preferences for outpatient training differ from recommendations for increased ambulatory training. Discordance was observed between reported problems with conflicting inpatient-outpatient responsibilities and preferences for models maintaining longitudinal clinic during inpatient rotations. Further study regarding benefits and barriers of ambulatory redesign is needed.

Redesigning the Regulatory Framework for Ambulatory Care Services in New York

PubMed Central

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

2014-01-01

Context 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. Methods 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. Findings 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 care services. From the state government's perspective, this clarification requires better reporting from new health care entities (eg, retail clinics), connections with regional and state health information technology hubs, and coordination among state agencies. A uniform nomenclature also would improve consumers’ understanding of rights and responsibilities. Finally, the regulatory mechanisms employed—from mandatory reporting to licensure to regional planning to the certificate of need—should remain flexible and match the degree of consensus regarding the appropriate regulatory path. Conclusions Few other

Reliability and Validity of Ambulatory Cognitive Assessments

PubMed Central

Sliwinski, Martin J.; Mogle, Jacqueline A.; Hyun, Jinshil; Munoz, Elizabeth; Smyth, Joshua M.; Lipton, Richard B.

2017-01-01

Mobile technologies are increasingly used to measure cognitive function outside of traditional clinic and laboratory settings. Although ambulatory assessments of cognitive function conducted in people’s natural environments offer potential advantages over traditional assessment approaches, the psychometrics of cognitive assessment procedures have been understudied. We evaluated the reliability and construct validity of ambulatory assessments of working memory and perceptual speed administered via smartphones as part of an ecological momentary assessment (EMA) protocol in a diverse adult sample (N=219). Results indicated excellent between-person reliability (≥.97) for average scores, and evidence of reliable within-person variability across measurement occasions (.41–.53). The ambulatory tasks also exhibited construct validity, as evidence by their loadings on working memory and perceptual speed factors defined by the in-lab assessments. Our findings demonstrate that averaging across brief cognitive assessments made in uncontrolled naturalistic settings provide measurements that are comparable in reliability to assessments made in controlled laboratory environments. PMID:27084835

Ambulatory Medication Reconciliation in Dialysis Patients: Benefits and Community Practitioners’ Perspectives

PubMed Central

Wilson, Jo-Anne S; Ladda, Matthew A; Tran, Jaclyn; Wood, Marsha; Poyah, Penelope; Soroka, Steven; Rodrigues, Glenn; Tennankore, Karthik

2017-01-01

Background Ambulatory medication reconciliation can reduce the frequency of medication discrepancies and may also reduce adverse drug events. Patients receiving dialysis are at high risk for medication discrepancies because they typically have multiple comorbid conditions, are taking many medications, and are receiving care from many practitioners. Little is known about the potential benefits of ambulatory medication reconciliation for these patients. Objectives To determine the number, type, and potential level of harm associated with medication discrepancies identified through ambulatory medication reconciliation and to ascertain the views of community pharmacists and family physicians about this service. Methods This retrospective cohort study involved patients initiating hemodialysis who received ambulatory medication reconciliation in a hospital renal program over the period July 2014 to July 2016. Discrepancies identified on the medication reconciliation forms for study patients were extracted and categorized by discrepancy type and potential level of harm. The level of harm was determined independently by a pharmacist and a nurse practitioner using a defined scoring system. In the event of disagreement, a nephrologist determined the final score. Surveys were sent to 52 community pharmacists and 44 family physicians involved in the care of study patients to collect their opinions and perspectives on ambulatory medication reconciliation. Results Ambulatory medication reconciliation was conducted 296 times for a total of 147 hemodialysis patients. The mean number of discrepancies identified per patient was 1.31 (standard deviation 2.00). Overall, 30% of these discrepancies were deemed to have the potential to cause moderate to severe patient discomfort or clinical deterioration. Survey results indicated that community practitioners found ambulatory medication reconciliation valuable for providing quality care to dialysis patients. Conclusions This study has

Administration in ambulatory care.

PubMed

Nardone, D A; Webb, D W

1989-10-01

Deficiencies in management of U.S. Department of Veterans Affairs (USDVA) ambulatory care programs have been documented in the literature and were reaffirmed by conference participants. These represent significant barriers to developing an effective and efficient system of outpatient health care delivery for veterans and to expanding educational opportunities for trainees. Based on impact and feasibility rankings from the symposium, review of the literature, and the personal experiences of USDVA ambulatory care managers, several recommendations emerged: (1) implement a system of matrix management; (2) invest in a leader; (3) develop "user-friendly" management information systems; (4) utilize existing resources efficiently; (5) embrace quality assurance; and (6) improve support from clerical and diagnostic services, nursing, and pharmacy personnel. Although intervention from leadership at the level of the USDVA Central Office will be necessary, many of these recommendations can be adopted by managers at the local facilities. The biggest challenge is to change the attitudes of clinical and support staff whose responsibilities have traditionally been inpatient-oriented.

[Importance of ambulatory blood pressure monitoring in adolescent hypertension].

PubMed

Páll, Dénes; Juhász, Mária; Katona, Eva; Lengyel, Szabolcs; Komonyi, Eva; Fülesdi, Béla; Paragh, György

2009-12-06

The prevalence of adolescent hypertension is increasing. The national epidemiological study found 2.5% prevalence, while it is 4.5% according to the newest international survey. Repeated casual blood pressure measurements, but not ambulatory blood pressure monitoring is needed for the diagnosis of adolescent hypertension on the basis of the presently available European guideline. At the last decade growing evidence came into light for ambulatory blood pressure monitoring in adolescence. These data show better correlation with end-organ damages than casual measurements. In patients with hypertension diagnosed based on repeated casual blood pressure measurements, 24-hour monitoring showed normal blood pressure in 21-47%, so this is the rate of white coat hypertension. Masked hypertension can also be diagnosed with the help of this method, which has a prevalence of 7-11%. We can also get useful data for secondary forms of hypertension. Until the appearance of the new European guidelines, more frequent use of ambulatory blood pressure monitoring is affordable. The confirmation of the diagnosis based on elevated casual blood pressure data is important. Ambulatory blood pressure monitoring is suggested in cases suspicious for white coat or masked hypertension, in cases of target organ damages or therapy resistant hypertension. Before administration of pharmaceutical therapy in adolescence hypertension - according to author's opinion - ambulatory blood pressure monitoring is absolutely necessary.

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

Agreement between ambulatory, home, and office blood pressure variability.

PubMed

Juhanoja, Eeva P; Niiranen, Teemu J; Johansson, Jouni K; Puukka, Pauli J; Jula, Antti M

2016-01-01

Ambulatory, home, and office blood pressure (BP) variability are often treated as a single entity. Our aim was to assess the agreement between these three methods for measuring BP variability. Twenty-four-hour ambulatory BP monitoring, 28 home BP measurements, and eight office BP measurements were performed on 461 population-based or hypertensive participants. Five variability indices were calculated for all measurement methods: SD, coefficient of variation, maximum-minimum difference, variability independent of the mean, and average real variability. Pearson's correlation coefficients were calculated for indices measured with different methods. The agreement between different measurement methods on the diagnoses of extreme BP variability (participants in the highest decile of variability) was assessed with kappa (κ) coefficients. SBP/DBP variability was greater in daytime (coefficient of variation: 9.8 ± 2.9/11.9 ± 3.6) and night-time ambulatory measurements (coefficient of variation: 8.6 ± 3.4/12.1 ± 4.5) than in home (coefficient of variation: 4.4 ± 1.8/4.7 ± 1.9) and office (coefficient of variation: 4.6 ± 2.4/5.2 ± 2.6) measurements (P < 0.001/0.001 for all). Pearson's correlation coefficients for systolic/diastolic daytime or night-time ambulatory-home, ambulatory-office, and home-office variability indices ranged between 0.07-0.25/0.12-0.23, 0.13-0.26/0.03-0.22 and 0.13-0.24/0.10-0.19, respectively, indicating, at most, a weak positive (r < 0.3) relationship. The agreement between measurement methods on diagnoses of extreme SBP/DBP variability was only slight (κ < 0.2), with the κ coefficients for daytime and night-time ambulatory-home, ambulatory-office, and home-office agreement varying between-0.014-0.20/0.061-0.15, 0.037-0.18/0.082-0.15, and 0.082-0.13/0.045-0.15, respectively. Shorter-term and longer-term BP variability assessed by different methods of BP measurement seem to correlate only weakly

Relationship Between 24-Hour Ambulatory Blood Pressure and Cognitive Function in Community-Living Older Adults: The UCSD Ambulatory Blood Pressure Study.

PubMed

Conway, Kyle S; Forbang, Nketi; Beben, Tomasz; Criqui, Michael H; Ix, Joachim H; Rifkin, Dena E

2015-12-01

Twenty-four-hour ambulatory blood pressure (BP) patterns have been associated with diminished cognitive function in hypertensive and very elderly populations. The relationship between ambulatory BP patterns and cognitive function in community-living older adults is unknown. We conducted a cross-sectional study in which 24-hour ambulatory BP, in-clinic BP, and cognitive function measures were obtained from 319 community-living older adults. The mean age was 72 years, 66% were female, and 13% were African-American. We performed linear regression with performance on the Montreal Cognitive Assessment (MoCA) as the primary outcome and 24-hour BP patterns as the independent variable, adjusting for age, sex, race/ethnicity, education, and comorbidities. Greater nighttime systolic dipping (P = 0.046) and higher 24-hour diastolic BP (DBP; P = 0.015) were both significantly associated with better cognitive function, whereas 24-hour systolic BP (SBP), average real variability, and ambulatory arterial stiffness were not. Higher 24-hour DBP and greater nighttime systolic dipping were significantly associated with improved cognitive function. Future studies should examine whether low 24-hour DBP and lack of nighttime systolic dipping predict future cognitive impairment. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Evolving vendor market for HITECH-certified ambulatory EHR products.

PubMed

Gold, Marsha; Hossain, Mynti; Charles, Dustin R; Furukawa, Michael F

2013-11-01

The ambitious goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act require rapid development and certification of new ambulatory electronic health record (EHR) products. To examine where the vendor market for EHR products stands now and the policy issues emerging from the market's evolution. Descriptive study with policy analysis. We had 3 main sources of information: (1) documents describing this evolving market, which is not well represented in peer-reviewed literature; (2) operational data on certified ambulatory EHR products and their use by Medicareeligible professionals attesting for meaningful use payments from January 2011 to October 2012; and (3) telephone interviews with 10 vendors that account for 57% of the market. Those attesting for Medicare meaningful use payments used ambulatory EHRs from 353 different vendors, although 16 firms accounted for 75% of the market. The Herfindahl-Hirschman Index showed the ambulatory EHR market to be highly competitive, particularly for practices of 50 or fewer professionals. The interviewed vendors and the external analysts agreed that stage 1 requirements set a relatively low bar for market entry, but that likely will change as requirements get more demanding. The HITECH Act met its initial goals to motivate growth of diverse ambulatory EHR products. A market shakeout may emerge, though current data reveal no signs of it. Policy makers can influence the shape and value of such a shakeout, and the extent of disruption, through their approach to certification and "usability" and "interoperability" strategies and requirements.

Preliminary study of percutaneous nephrolithotomy on an ambulatory basis.

PubMed

El-Tabey, Magdy Ahmed; Abd-Allah, Osama Abdel-Wahab; Ahmed, Ahmed Sebaey; El-Barky, Ehab Mohammed; Noureldin, Yasser Abdel-Sattar

2013-02-01

Preliminary study to assess the feasibility and safety of percutaneous nephrolithotomy (PCNL) as an ambulatory procedure. Between February 2011 and September 2012, 84 patients with renal calculi fulfilling the inclusion criteria were admitted to the Urology Department of Benha University Hospitals for PCNL. All patients were subjected to a full medical history, clinical, laboratory and radiological examinations. Tubeless PCNLs were done in the supine position, and an antegrade double-J stent was inserted. Operative time and intraoperative complications were recorded. Postoperatively, the hematocrit value, postoperative pain and analgesics, need of blood transfusion, stone-free rate, and length of hospital stay were recorded. Stable patients that could be safely discharged within 24 hours after surgery were considered ambulatory. All cases of tubeless PCNL were successfully done and no cases converted to open surgery. The overall stone-free rate was 91.7%, the mean postoperative pain score measured by the visual analog scale was 4.4 ± 1.2, the mean overall hematocrit deficit was 4.8 ± 2.2% and the mean hospital stay was 33.4 ± 17.5 hours. Ambulatory PCNL was accomplished in 60 out of 84 patients (71.4%) and double-J stents were removed 7-10 days postoperatively. In the non-ambulatory cases, double-J stents were removed after auxillary procedures were done according to each case. PCNL can be safely done on an ambulatory basis under strict criteria, but further studies are needed to confirm and expand these findings.

The fraud and abuse statute and investor-owned ambulatory surgery centers.

PubMed

Becker, Scott; Harned, Nicholas

2002-04-01

The growth in the number of ambulatory surgery centers, coupled with the unique guidance provided by the OIG in this area, provide a fascinating legal and regulatory environment for ambulatory surgery centers.

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.

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. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835249. © 2016 American Heart Association, Inc.

Considerations for Providing Ambulatory Pharmacy Services for Pediatric Patients.

PubMed

Lampkin, Stacie J; Gildon, Brooke; Benavides, Sandra; Walls, Kelly; Briars, Leslie

2018-01-01

Pediatric clinical pharmacists are an integral part of the health care team. By practicing in an ambulatory care clinic, they can reduce the risk of medication errors, improve health outcomes, and enhance patient care. Unfortunately, because of limited data, misconceptions surrounding the role of pharmacists, and reimbursement challenges, there may be difficulty in establishing or expanding pediatric clinical pharmacy services to an ambulatory care setting. The purpose of this paper is to provide an overview of considerations for establishing or expanding pharmacy services in a pediatric ambulatory care clinic. The primer will discuss general and pediatric-specific pharmacy practice information, as well as potential barriers, and recommendations for identifying a practice site, creating a business plan, and integrating these services into a clinic setting.

77 FR 37680 - Medicare and Medicaid Programs; Application From the Accreditation Association for Ambulatory...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-22

...] Medicare and Medicaid Programs; Application From the Accreditation Association for Ambulatory Health Care... of an application from the Accreditation Association for Ambulatory Health Care for continued... by CMS. The Accreditation Association for Ambulatory Health Care (AAAHC) current term of approval for...

Hospital readmission after ambulatory laparoscopic cholecystectomy: incidence and predictors.

PubMed

Rosero, Eric B; Joshi, Girish P

2017-11-01

The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy. The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions. A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions. This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers. Copyright © 2017 Elsevier Inc. All rights reserved.

Ambulatory (24 hour) blood pressure monitoring in police officers.

PubMed

Tomei, Francesco; Rosati, Maria Valeria; Baccolo, Tiziana Paola; Cherubini, Emilia; Ciarrocca, Manuela; Caciari, Tiziana; Tomao, Enrico

2004-05-01

The aim of the study is to evaluate, by ambulatory (24 h) blood pressure monitoring (ABPM), whether police officers exposed to urban pollutants and possible psycho-social stressors could be at risk of changes in ambulatory systolic blood pressure (SBP), and ambulatory diastolic blood pressure (DBP) compared to controls. After excluding the principal confounding factors, police officers and controls have been subdivided into non-smoker and smoker subjects. Police officers were compared by sex, age, length of service, family history of cardiovascular disease, serum total cholesterol, serum HDL cholesterol, serum LDL cholesterol, plasma triglyceride, body mass index (BMI kg/m (2)) and drinking habits with controls. Smoker police officers were compared with controls also by the smoking habit. In the non smoker group 77 police officers with outdoor activity (38 men and 39 women) and 87 controls with indoor activity (43 men and 44 women) were studied. In the smoker group 43 police officers (21 men and 22 women) and 29 controls (15 men and 14 women) were studied. In non smoker male police officers ambulatory SBP mean values during 24 h, during day-time and during night-time were significantly higher than controls. In the same group ambulatory DBP values during 24 h and between 6 AM and 11 AM and between 10 PM and 6 AM were significantly higher in police officers than controls. The results suggest that occupational exposure to urban pollutants and possible psycho-social stressors could cause changes in ABPM values in male police officers compared to controls.

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

PubMed

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

2008-02-01

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

Heritability and Temporal Stability of Ambulatory Autonomic Stress Reactivity in Unstructured 24-Hour Recordings.

PubMed

Neijts, Melanie; van Lien, Rene; Kupper, Nina; Boomsma, Dorret; Willemsen, Gonneke; de Geus, Eco J C

2015-10-01

Measurements of ambulatory autonomic reactivity can help with our understanding of the long-term health consequences of exposure to psychosocial stress in real-life settings. In this study, unstructured 24-hour ambulatory recordings of cardiac parasympathetic and sympathetic control were obtained in 1288 twins and siblings, spanning both work time and leisure time. These data were used to define two ambulatory baseline (sleep, leisure) and four stress conditions (wake, work, work_sitting, work_peak) from which six ambulatory stress reactivity measures were derived. The use of twin families allowed for estimation of heritability and testing for the amplification of existing or emergence of new genetic variance during stress compared with baseline conditions. Temporal stability of ambulatory reactivity was assessed in 62 participants and was moderate to high over a 3-year period (0.36 < r < 0.91). Depending on the definition of ambulatory reactivity used, significant heritability was found, ranging from 29% to 40% for heart rate, 34% to 47% for cardiac parasympathetic control (indexed as respiratory sinus arrhythmia), and 10% to 19% for cardiac sympathetic control (indexed as the preejection period). Heritability of ambulatory reactivity was largely due to newly emerging genetic variance during stress compared with periods of rest. Interestingly, reactivity to short standardized stressors was poorly correlated with the ambulatory reactivity measures implying poor laboratory-real-life correspondence. Ambulatory autonomic reactivity extracted from an unstructured real-life setting shows reliable, stable, and heritable individual differences. Real-life situations uncover a new and different genetic variation compared with that seen in resting baseline conditions, including sleep.

The evolution of ambulatory ECG monitoring.

PubMed

Kennedy, Harold L

2013-01-01

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

[Survey of pain after ambulatory surgery: An internet-based instrument].

PubMed

Schwarze, C; Zenz, D; Orlowski, O; Wempe, C; Van Aken, H; Zahn, P; Maier, C; Pogatzki-Zahn, E M

2016-04-01

Pain after surgery continues to be undermanaged. Studies and initiatives aiming to improve the management of postoperative pain are growing; however, most studies focus on inpatients and pain on the first day after surgery. The management of postoperative pain after ambulatory surgery and for several days thereafter is not yet a major focus. One reason is the low return rate of the questionnaires in the ambulatory sector. This article reports the development and feasibility of a web-based electronic data collection system to examine pain and pain-related outcome on predefined postoperative days after ambulatory surgery. In this prospective pilot study 127 patients scheduled for ambulatory surgery were asked to participate in a survey to evaluate aspects related to pain after ambulatory surgery. The data survey was divided in (1) a preoperative, intraoperative and postoperative part and (2) a postoperative internet-based electronic questionnaire which was sent via e-mail link to the patient on days 1, 3 and 7 after surgery. A software was developed using a PHP-based platform to send e-mails and retrieve the data after web-based entries via a local browser. Feasibility, internet-based hitches and compliance were assessed by an additional telephone call after day 7. A total of 100 patients (50 female) between 18 and 71 years (mean 39.1 ± 12.7 years) were included in the pilot study. Return rates of the electronic questionnaires were 86% (days 3 and 7) and 91% (day 1 after surgery). All 3 electronic questionnaires were answered by 82% of patients. Aspects influencing the return rate of questionnaires were work status but not age, gender, education level and preoperative pain. Telephone interviews were performed with 81 patients and revealed high operability of the internet-based survey without any major problems. The user-friendly feasibility and operability of this internet-based electronic data survey system explain the high compliance and return rate of

Ambulatory intravenous ceftriaxone in paediatric A&E: a useful alternative to hospital admission?

PubMed

Smith, Jennifer K; Alexander, Saji; Abrahamson, Ed

2011-10-01

Treatment of children with intravenous ceftriaxone on an ambulatory basis is described. This allows a child to remain at home, but also be reviewed regularly when attending the Emergency Department for antibiotics. Indications for, and length of, treatment and laboratory parameters were recorded. Also, a survey of children's parents was undertaken to ascertain opinions regarding ambulatory treatment. 36 patients were treated with ambulatory ceftriaxone over 4 months. Indications included fever without focus, tonsillitis, periorbital cellulitis, urinary tract infection, petechial rash and lymphadenitis. Median duration of treatment was 2.3 days. There was no occult bacteraemia but five positive urine cultures. There was one failure of treatment with subsequent admission for alternative intravenous antibiotics. Parental opinion favours ambulatory treatment, with 94% of parents acknowledging they would choose it again in similar circumstances. Cost analysis favours ambulatory treatment based on predicted costs of a similar length of inpatient stay.

Ambulatory estimation of foot placement during walking using inertial sensors.

PubMed

Martin Schepers, H; van Asseldonk, Edwin H F; Baten, Chris T M; Veltink, Peter H

2010-12-01

This study proposes a method to assess foot placement during walking using an ambulatory measurement system consisting of orthopaedic sandals equipped with force/moment sensors and inertial sensors (accelerometers and gyroscopes). Two parameters, lateral foot placement (LFP) and stride length (SL), were estimated for each foot separately during walking with eyes open (EO), and with eyes closed (EC) to analyze if the ambulatory system was able to discriminate between different walking conditions. For validation, the ambulatory measurement system was compared to a reference optical position measurement system (Optotrak). LFP and SL were obtained by integration of inertial sensor signals. To reduce the drift caused by integration, LFP and SL were defined with respect to an average walking path using a predefined number of strides. By varying this number of strides, it was shown that LFP and SL could be best estimated using three consecutive strides. LFP and SL estimated from the instrumented shoe signals and with the reference system showed good correspondence as indicated by the RMS difference between both measurement systems being 6.5 ± 1.0 mm (mean ± standard deviation) for LFP, and 34.1 ± 2.7 mm for SL. Additionally, a statistical analysis revealed that the ambulatory system was able to discriminate between the EO and EC condition, like the reference system. It is concluded that the ambulatory measurement system was able to reliably estimate foot placement during walking. Copyright © 2010 Elsevier Ltd. All rights reserved.

Complex ambulatory settings demand scheduling systems.

PubMed

Ross, K M

1998-01-01

Practice management systems are becoming more and more complex, as they are asked to integrate all aspects of patient and resource management. Although patient scheduling is a standard expectation in any ambulatory environment, facilities and equipment resource scheduling are additional functionalities of scheduling systems. Because these functions were not typically managed in manual patient scheduling, often the result was resource mismanagement, along with a potential negative impact on utilization, patient flow and provider productivity. As ambulatory organizations have become more seasoned users of practice management software, the value of resource scheduling has become apparent. Appointment scheduling within a fully integrated practice management system is recognized as an enhancement of scheduling itself and provides additional tools to manage other information needs. Scheduling, as one component of patient information management, provides additional tools in these areas.

Acute and Chronic Effects of Aerobic and Resistance Exercise on Ambulatory Blood Pressure

PubMed Central

Cardoso, Crivaldo Gomes; Gomides, Ricardo Saraceni; Queiroz, Andréia Cristiane Carrenho; Pinto, Luiz Gustavo; da Silveira Lobo, Fernando; Tinucci, Tais; Mion, Décio; de Moraes Forjaz, Claudia Lucia

2010-01-01

Hypertension is a ubiquitous and serious disease. Regular exercise has been recommended as a strategy for the prevention and treatment of hypertension because of its effects in reducing clinical blood pressure; however, ambulatory blood pressure is a better predictor of target-organ damage than clinical blood pressure, and therefore studying the effects of exercise on ambulatory blood pressure is important as well. Moreover, different kinds of exercise might produce distinct effects that might differ between normotensive and hypertensive subjects. The aim of this study was to review the current literature on the acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure in normotensive and hypertensive subjects. It has been conclusively shown that a single episode of aerobic exercise reduces ambulatory blood pressure in hypertensive patients. Similarly, regular aerobic training also decreases ambulatory blood pressure in hypertensive individuals. In contrast, data on the effects of resistance exercise is both scarce and controversial. Nevertheless, studies suggest that resistance exercise might acutely decrease ambulatory blood pressure after exercise, and that this effect seems to be greater after low-intensity exercise and in patients receiving anti-hypertensive drugs. On the other hand, only two studies investigating resistance training in hypertensive patients have been conducted, and neither has demonstrated any hypotensive effect. Thus, based on current knowledge, aerobic training should be recommended to decrease ambulatory blood pressure in hypertensive individuals, while resistance exercise could be prescribed as a complementary strategy. PMID:20360924

Ambulatory blood pressure monitoring: Is 24 hours necessary?

PubMed

Vornovitsky, Michael; McClintic, Benjamin R; Beck, G Ronald; Bisognano, John D

2013-01-01

The variability of blood pressure (BP) makes any single measurement a poor indicator of a patient's true BP. Multiple studies have confirmed the superiority of ambulatory BP measurements over clinic BP measurements in predicting cardiovascular risk; however, this method presents the problem of patient acceptance as it causes frequent arm discomfort and sleep disturbance. We hypothesized that 6 h of daytime BP measurements would result in slightly higher BP readings, yet reveal similar clinical decision making when compared to 24 h of BP measurements. The source for writing this article was a retrospective analysis of 30 patients who underwent ambulatory BP monitoring. Data obtained included: age, sex, ethnicity, baseline medical problems, medications, laboratory values, reason given for ordering 24-h ambulatory BP measurements, ambulatory BP measurements, and a subsequent decision to change medication. The average BP of the 24-h measurements was 127/75 mm Hg and the average BP of the 6-h daytime measurements was 131/79 mm Hg (SD 15, p = 0.009). Twenty-six out of 30 patients were at goal or pre-hypertensive. Two out of 30 patients had stage 1 hypertension and 2 out of 30 patients had stage 2 hypertension. Thirteen out of 30 patients had nocturnal dipping. Twelve out of 30 patients had a change in medication, but those changes were not associated with the presence or absence of nocturnal dipping (p = 0.5) or other factors beyond mean BP. Although there was a statistically significant, 4 mm Hg systolic difference between 24-h and 6-h average BP readings, there was no evidence that this difference led to changes in clinical management. The presence or absence of nocturnal dipping was not associated with a change in medication. We conclude that 6-h daytime ambulatory BP measurements provide sufficient information to guide clinical decision making without the problems of patient acceptance, arm discomfort, and sleep disturbance associated with 24-h BP measurements.

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.

77 FR 70783 - Medicare and Medicaid Programs; Approval of the Accreditation Association for Ambulatory Health...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-27

...] Medicare and Medicaid Programs; Approval of the Accreditation Association for Ambulatory Health Care (AAAHC... announces our decision to approve the Accreditation Association for Ambulatory Health Care (AAAHC) for... Ambulatory Health Care's (AAAHC) current term of approval for their ASC accreditation program expires on...

Anaesthesia in outer space: the ultimate ambulatory setting?

PubMed

Komorowski, Matthieu; Fleming, Sarah; Hinkelbein, Jochen

2016-12-01

Missions to the Moon or more distant planets are planned in the next future, and will push back the limits of our experience in providing medical support in remote environments. Medical preparedness is ongoing, and involves planning for emergency surgical interventions and anaesthetic procedures. This review will summarize what principles of ambulatory anaesthesia on Earth could benefit the environment of a space mission with its unique constraints. Ambulatory anaesthesia relies on several principles such as improved patient pathway, correct patient selection, optimized procedural strategies to hasten recovery and active prevention of postoperative complications. Severe limitations in the equipment available and the skills of the crew members represent the key factors to be taken into account when designing the on-board medical system for future interplanetary space missions. The application of some of the key principles of ambulatory anaesthesia, as well as recent advances in anaesthetic techniques and better understanding of human adaptation to the space environment might allow nonanaesthesiologist physicians to perform common anaesthetic procedures, whilst maximizing crew safety and minimizing the impact of medical events on the mission.

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

PubMed

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

2016-01-01

Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed.

Ambulatory surgery centers best practices for the 90s.

PubMed

Hoover, J A

1994-05-01

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

The Influence of Ambulatory Aid on Lower-Extremity Muscle Activation During Gait.

PubMed

Sanders, Michael; Bowden, Anton E; Baker, Spencer; Jensen, Ryan; Nichols, McKenzie; Seeley, Matthew K

2018-05-10

Foot and ankle injuries are common and often require a nonweight-bearing period of immobilization for the involved leg. This nonweight-bearing period usually results in muscle atrophy for the involved leg. There is a dearth of objective data describing muscle activation for different ambulatory aids that are used during the aforementioned nonweight-bearing period. To compare activation amplitudes for 4 leg muscles during (1) able-bodied gait and (2) ambulation involving 3 different ambulatory aids that can be used during the acute phase of foot and ankle injury care. Within-subject, repeated measures. University biomechanics laboratory. Sixteen able-bodied individuals (7 females and 9 males). Each participant performed able-bodied gait and ambulation using 3 different ambulatory aids (traditional axillary crutches, knee scooter, and a novel lower-leg prosthesis). Muscle activation amplitude quantified via mean surface electromyography amplitude throughout the stance phase of ambulation. Numerous statistical differences (P < .05) existed for muscle activation amplitude between the 4 observed muscles, 3 ambulatory aids, and able-bodied gait. For the involved leg, comparing the 3 ambulatory aids: (1) knee scooter ambulation resulted in the greatest vastus lateralis activation, (2) ambulation using the novel prosthesis and traditional crutches resulted in greater biceps femoris activation than knee scooter ambulation, and (3) ambulation using the novel prosthesis resulted in the greatest gastrocnemius activation (P < .05). Generally speaking, muscle activation amplitudes were most similar to able-bodied gait when subjects were ambulating using the knee scooter or novel prosthesis. Type of ambulatory aid influences muscle activation amplitude. Traditional axillary crutches appear to be less likely to mitigate muscle atrophy during the nonweighting, immobilization period that often follows foot or ankle injuries. Researchers and clinicians should consider

Impact of pharmacist interventions on cost avoidance in an ambulatory cancer center.

PubMed

Randolph, Laura A; Walker, Cheri K; Nguyen, Ann T; Zachariah, Subi R

2018-01-01

Objective To provide a foundation to justify the presence of a full-time clinical pharmacist in the ambulatory cancer center in addition to an existing centralized pharmacist through cost avoidance calculation and patient and staff satisfaction surveys. Methods The prospective, pilot study took place in an ambulatory cancer center over four weeks in 2014. Cost avoidance values were assigned to interventions performed by a pharmacy resident, who was present in the ambulatory cancer center during clinic hours, along with a centralized oncology pharmacist routinely working with the cancer center. Anonymous patient and staff satisfaction surveys based on a 5-point Likert scale were distributed to assess the perceived benefit of a pharmacist located in the ambulatory cancer center. Results Data collection took place over approximately one month. After evaluation of 962 interventions from both pharmacists, the estimated cost avoidance was US$282,741 per pharmacist per year, yielding a net benefit of US$138,441. The most common interventions made by the resident included chemotherapy regimen review (n = 290, 69%) and patient counseling (n = 102, 24%), while the majority of the centralized pharmacist's interventions was chemotherapy regimen review (n = 525, 97%). Results from the anonymous patient and staff surveys revealed an overall positive perception of the pharmacy resident while in the ambulatory cancer center. Conclusion A full-time clinical pharmacist in an ambulatory cancer center is both financially beneficial and positively perceived by patients and staff.

Improving adherence to the Epic Beacon ambulatory workflow.

PubMed

Chackunkal, Ellen; Dhanapal Vogel, Vishnuprabha; Grycki, Meredith; Kostoff, Diana

2017-06-01

Computerized physician order entry has been shown to significantly improve chemotherapy safety by reducing the number of prescribing errors. Epic's Beacon Oncology Information System of computerized physician order entry and electronic medication administration was implemented in Henry Ford Health System's ambulatory oncology infusion centers on 9 November 2013. Since that time, compliance to the infusion workflow had not been assessed. The objective of this study was to optimize the current workflow and improve the compliance to this workflow in the ambulatory oncology setting. This study was a retrospective, quasi-experimental study which analyzed the composite workflow compliance rate of patient encounters from 9 to 23 November 2014. Based on this analysis, an intervention was identified and implemented in February 2015 to improve workflow compliance. The primary endpoint was to compare the composite compliance rate to the Beacon workflow before and after a pharmacy-initiated intervention. The intervention, which was education of infusion center staff, was initiated by ambulatory-based, oncology pharmacists and implemented by a multi-disciplinary team of pharmacists and nurses. The composite compliance rate was then reassessed for patient encounters from 2 to 13 March 2015 in order to analyze the effects of the determined intervention on compliance. The initial analysis in November 2014 revealed a composite compliance rate of 38%, and data analysis after the intervention revealed a statistically significant increase in the composite compliance rate to 83% ( p < 0.001). This study supports a pharmacist-initiated educational intervention can improve compliance to an ambulatory, oncology infusion workflow.

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.

Accounting for the move to ambulatory patient groups.

PubMed

Boyagian, H R; Dessingue, R F

1998-07-01

This article focuses on the cost accounting challenge an ambulatory patient group (APG)-like-based prospective payment system presents to providers and the issues associated with that challenge. In particular, how can costs be identified, how can the differences in costs be associated with alternative settings, and how do costs identified through a detailed resource costing methodology compare to estimates using alternative measures? The results presented suggest that decisions made based on current measures of ambulatory cost (i.e., charge-based measures) need to be reexamined. These decisions could include which services to provide, what setting is appropriate, and where marketshare opportunities exist.

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)

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…

Antimicrobial usage in ambulatory patients with respiratory infections in Taiwan, 2001.

PubMed

Ho, Monto; Hsiung, Chao Agnes; Yu, Hui-Tzu; Chi, Cheng-Liang; Yin, Hsiao-Chuan; Chang, Hong-Jen

2004-02-01

Excess use of antimicrobials by ambulatory patients is a determinant of antimicrobial resistance. This study investigated the types of illnesses for which antimicrobials were prescribed and the amounts prescribed with special emphasis on respiratory infections for the year in which the Bureau of National Health Insurance (BNHI) enforced a policy to restrict antimicrobials for upper respiratory infections. The number of ambulatory patients seen and the types of ambulatory facilities in Taiwan were also described. Raw data were obtained from the BNHI database on every 500 th visit in 2001. Medical diagnoses were categorized according to the ICD-9-CM system. Antimicrobial consumption was expressed in defined daily doses per 1000 population per day (DDD/1000/day). Among the population of 22.3 million in Taiwan, there were 285.8 million ambulatory patient visits (12.8 per person), including 108.9 million visits (4.9 per person) for respiratory infections, of which 62.7 million (2.8 per person) were for upper respiratory infections (URI). Antimicrobial consumption was 19.83 DDD/1000/day [standard error (SE), 0.00055], of which 9.97 DDD/1000/day (SE, 0.00047) were for respiratory infections and 4.03 DDD/1000/day (0.00055) were for URI. 23.6% of visits for URI entailed a prescription for antimicrobials. About two-thirds (66.5%) of ambulatory patients were seen in clinics, mostly private ones, and 67.6% of all antimicrobials were received there. Aminopenicillins and cephalosporins constituted 35.2% and 19.5%, respectively, of antimicrobials prescribed. Despite the new BNHI rule restricting antimicrobial usage for URI, Taiwan still has an excessive number of ambulatory patient visits, especially for respiratory infections and URI. The majority of antimicrobials used were for URI. They were mostly prescribed in private clinics rather than hospital outpatient departments.

Ambulatory thyroidectomy: an anesthesiologist's perspective.

PubMed

Murray, Benjamin; Tandon, Sankalap; Dempsey, Ged

2017-01-01

Thyroidectomy has been performed on an inpatient basis because of concerns regarding postoperative complications. These include cervical hematoma, bilateral recurrent laryngeal nerve injury and symptomatic hypocalcemia. We have reviewed the current available evidence and aimed to collate published data to generate incidence of the important complications. We performed a literature search of Medline, EMBASE and the Cochrane database of randomized trials. One hundred sixty papers were included. Twenty-one papers fulfilled inclusion criteria. Thirty thousand four hundred fifty-three day-case thyroid procedures were included. Ten papers were prospective and 11 retrospective. The incidences of complications were permanent vocal cord paralysis 7/30259 (0.02%), temporary hypocalcemia 129/4444 (2.9%), permanent hypocalcemia 405/29203 (1.39%), cervical hematoma 145/30288 (0.48%) and readmission rate 105/29609 (0.35%). Analysis of cervical hematoma data demonstrated that in only 3/14 cases the hematoma presented as an inpatient, and in the remaining 11/14, it occurred late, with a range of 2-9 days. There is a paucity of data relating to anesthetic techniques associated with ambulatory thyroidectomy. Cost comparison between outpatient and inpatient thyroidectomy was reported in three papers. Cost difference ranged from $676 to $2474 with a mean saving of $1301 with ambulatory thyroidectomy. There is a body of evidence that suggests that ambulatory thyroidectomy in the hands of experienced operating teams within an appropriate setting can be performed with acceptable risk profile. In most circumstances, this will be limited to hemithyroidectomies to reduce or avoid the potential for additional morbidity. We have found little evidence to support the use of one anesthetic technique over another. The rates of hospital admission and readmission related to anesthetic factors appear to be low and predominantly related to pain and postoperative nausea and vomiting. A balanced

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

Pros and cons of the ambulatory surgery center joint venture.

PubMed

Giannini, Deborah

2008-01-01

If a physician group has determined that it has a realistic patient base to establish an ambulatory surgery center, it may be beneficial to consider a partner to share the costs and risks of this new joint venture. Joint ventures can be a benefit or liability in the establishment of an ambulatory surgery center. This article discusses the advantages and disadvantages of a hospital physician-group joint venture.

Return on Investment for the Baccalaureate-Prepared RN in Ambulatory Care.

PubMed

Zolotorofe, Irene; Fortini, Robert; Hash, Pam; Daniels, Angel; Orsolini, Liana; Mazzoccoli, Andrea; Gerardi, Tina

2018-03-01

Evidence supports the return on investment for an RN in ambulatory care. Utilizing RNs to their fullest potential in ambulatory practices is essential to effectively manage population health. Bon Secours Health System launched a new role, patient navigator RNs, to ensure seamless transitions of complex patients across care settings, resulting in better patient outcomes and a financial return.

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. Copyright © 2012 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

Ambulatory surgery centers--current business and legal issues.

PubMed

Becker, S; Biala, M

2000-01-01

This article explores a handful of critical trends that have broad implications for ambulatory surgery centers and health care entities as a whole. As of the year 2000, the health care delivery system is experiencing broad changes and reconstruction in a variety of manners. One of the largest changes revolves around the accelerating movement of patient care from inpatient models to outpatient models, and the commensurate investment and development in outpatient systems and outpatient bricks and mortar. This metamorphosis is particularly evident as it relates to freestanding ambulatory surgery centers. This change in health care delivery will prove to have severe economic impacts on many of the nation's hospital systems.

A Comprehensive Computer Package for Ambulatory Surgical Facilities

PubMed Central

Kessler, Robert R.

1980-01-01

Ambulatory surgical centers are a cost effective alternative to hospital surgery. Their increasing popularity has contributed to heavy case loads, an accumulation of vast amounts of medical and financial data and economic pressures to maintain a tight control over “cash flow”. Computerization is now a necessity to aid ambulatory surgical centers to maintain their competitive edge. An on-line system is especially necessary as it allows interactive scheduling of surgical cases, immediate access to financial data and rapid gathering of medical and statistical information. This paper describes the significant features of the computer package in use at the Salt Lake Surgical Center, which processes 500 cases per month.

Ambulatory versus home versus clinic blood pressure: the association with subclinical cerebrovascular diseases: the Ohasama Study.

PubMed

Hara, Azusa; Tanaka, Kazushi; Ohkubo, Takayoshi; Kondo, Takeo; Kikuya, Masahiro; Metoki, Hirohito; Hashimoto, Takanao; Satoh, Michihiro; Inoue, Ryusuke; Asayama, Kei; Obara, Taku; Hirose, Takuo; Izumi, Shin-Ichi; Satoh, Hiroshi; Imai, Yutaka

2012-01-01

The usefulness of ambulatory, home, and casual/clinic blood pressure measurements to predict subclinical cerebrovascular diseases (silent cerebrovascular lesions and carotid atherosclerosis) was compared in a general population. Data on ambulatory, home, and casual/clinic blood pressures and brain MRI to detect silent cerebrovascular lesions were obtained in 1007 subjects aged ≥55 years in a general population of Ohasama, Japan. Of the 1007 subjects, 583 underwent evaluation of the extent of carotid atherosclerosis. Twenty-four-hour, daytime, and nighttime ambulatory and home blood pressure levels were closely associated with the risk of silent cerebrovascular lesions and carotid atherosclerosis (all P<0.05). When home and one of the ambulatory blood pressure values were simultaneously included in the same regression model, each of the ambulatory blood pressure values remained a significant predictor of silent cerebrovascular lesions, whereas home blood pressure lost its predictive value. Of the ambulatory blood pressure values, nighttime blood pressure was the strongest predictor of silent cerebrovascular lesions. The home blood pressure value was more closely associated with the risk of carotid atherosclerosis than any of the ambulatory blood pressure values when home and one of the ambulatory blood pressure values were simultaneously included in the same regression model. The casual/clinic blood pressure value had no significant association with the risk of subclinical cerebrovascular diseases. Although the clinical indications for ambulatory blood pressure monitoring and home blood pressure measurements may overlap, the clinical significance of each method for predicting target organ damage may differ for different target organs.

Relationship Between 24-Hour Ambulatory Central Systolic Blood Pressure and Left Ventricular Mass: A Prospective Multicenter Study.

PubMed

Weber, Thomas; Wassertheurer, Siegfried; Schmidt-Trucksäss, Arno; Rodilla, Enrique; Ablasser, Cornelia; Jankowski, Piotr; Lorenza Muiesan, Maria; Giannattasio, Cristina; Mang, Claudia; Wilkinson, Ian; Kellermair, Jörg; Hametner, Bernhard; Pascual, Jose Maria; Zweiker, Robert; Czarnecka, Danuta; Paini, Anna; Salvetti, Massimo; Maloberti, Alessandro; McEniery, Carmel

2017-12-01

We investigated the relationship between left ventricular mass and brachial office as well as brachial and central ambulatory systolic blood pressure in 7 European centers. Central systolic pressure was measured with a validated oscillometric device, using a transfer function, and mean/diastolic pressure calibration. M-mode images were obtained by echocardiography, and left ventricular mass was determined by one single reader blinded to blood pressure. We studied 289 participants (137 women) free from antihypertensive drugs (mean age: 50.8 years). Mean office blood pressure was 145/88 mm Hg and mean brachial and central ambulatory systolic pressures were 127 and 128 mm Hg, respectively. Mean left ventricular mass was 93.3 kg/m 2 , and 25.6% had left ventricular hypertrophy. The correlation coefficient between left ventricular mass and brachial office, brachial ambulatory, and central ambulatory systolic pressure was 0.29, 0.41, and 0.47, respectively ( P =0.003 for comparison between brachial office and central ambulatory systolic pressure and 0.32 for comparison between brachial and central ambulatory systolic pressure). The results were consistent for men and women, and young and old participants. The areas under the curve for prediction of left ventricular hypertrophy were 0.618, 0.635, and 0.666 for brachial office, brachial, and central ambulatory systolic pressure, respectively ( P =0.03 for comparison between brachial and central ambulatory systolic pressure). In younger participants, central ambulatory systolic pressure was superior to both other measurements. Central ambulatory systolic pressure, measured with an oscillometric cuff, shows a strong trend toward a closer association with left ventricular mass and hypertrophy than brachial office/ambulatory systolic pressure. URL: https://www.clinicaltrials.gov. Unique identifier: NCT01278732. © 2017 American Heart Association, Inc.

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

Can abdominal surgical emergencies be treated in an ambulatory setting?

PubMed

Genser, L; Vons, C

2015-12-01

The performance of emergency abdominal surgery in an outpatient setting is increasingly the order of the day in France. This review evaluates the feasibility and reliability of ambulatory surgical treatment of the most common abdominal emergencies: appendectomy for acute appendicitis and cholecystectomy for acute complications of gallstone disease (acute cholecystitis and gallstone pancreatitis). This study evaluates surgical procedures performed on an ambulatory basis according to the international definition (admission in the morning, discharge in the evening with a hospital stay of less than 12 hours). Just as for elective surgery, eligibility of patients for an ambulatory approach depends on the capacities of the surgical and anesthesia team: to manage the risks, particularly the risk of deferring surgery until the morning); to prevent or treat post-operative symptoms like pain, nausea, vomiting, re-ambulation in order to permit rapid post-operative discharge. Recent studies have shown that appendectomy for non-complicated acute appendicitis can be deferred for up to 12 hours without any increase in danger. Many other studies have shown that early discharge after appendectomy for acute non-complicated appendicitis is feasible and safe. Nonetheless, there is only one published series of truly ambulatory appendectomies. The results were excellent. Patients who presented in the afternoon were brought back for operation the following morning. The appropriate timing for performance of cholecystectomy in patients with acute calculous cholecystitis or gallstone pancreatitis has not been well defined, but is always somewhat delayed relative to the onset of symptoms. To minimize operative complications, cholecystectomy for acute calculous cholecystitis should probably be performed between 24 and 72 hours after diagnosis. Cholecystectomy for gallstone pancreatitis should probably not be delayed longer than a week; the need to keep the patient hospitalized during the

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

PubMed

Wang-Romjue, Pauline

2018-04-01

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

Assessing patient safety in Canadian ambulatory surgery facilities: A national survey

PubMed Central

Ahmad, Jamil; Ho, Olivia A; Carman, Wayne W; Thoma, Achilles; Lalonde, Donald H; Lista, Frank

2014-01-01

BACKGROUND: There has been increased interest regarding patient safety and standards of care in Canadian ambulatory surgery facilities where surgical procedures are performed. The Canadian Association for Accreditation of Ambulatory Surgical Facilities (CAAASF) is a national organization formed to establish and maintain standards to ensure that surgical procedures conducted outside of public hospitals are performed safely. OBJECTIVE: To determine how many procedures are performed annually at CAAASF member sites, and to examine complication rates and several key patient safety practices. METHODS: All 69 facilities accredited by the CAAASF were surveyed. The survey focused on procedural data, complication rates and patient safety interventions. RESULTS: In 2010, 40,240 estimated procedures were performed. A total of 263 (0.007%) complications were reported. Sixteen (0.0004%) patients required reoperations in hospital and 19 (0.0004%) patients required transfer to hospital on the day of surgery. There were only two mortalities within 30 days of surgery reported in the past five years. With regard to patient safety practices, 93% used antimicrobial prophylaxis, 100% used strategies to maintain normothermia and 82% used measures for venous thromboembolism prevention. CONCLUSION: The present study is the first to report on the Canadian experience in ambulatory surgery facilities and provides insight into current practices at these facilities. Appropriate accreditation of ambulatory surgery facilities, well-established patient safety-related standards of care, careful patient selection and procedures performed by qualified health care professionals with appropriate certification practicing within the scope of their practice form the basis for safe and effective ambulatory surgery. PMID:25152645

Diagnoses Treated in Ambulatory Care Among Homeless-Experienced Veterans

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

Ambulatory orthopaedic surgery patients' emotions when using different patient education methods.

PubMed

Heikkinen, Katja; Salanterä, Sanna; Leppänen, Tiina; Vahlberg, Tero; Leino-Kilpi, Helena

2012-07-01

A randomised controlled trial was used to evaluate elective ambulatory orthopaedic surgery patients' emotions during internet-based patient education or face-to-face education with a nurse. The internet-based patient education was designed for this study and patients used websites individually based on their needs. Patients in the control group participated individually in face-to-face patient education with a nurse in the ambulatory surgery unit. The theoretical basis for both types of education was the same. Ambulatory orthopaedic surgery patients scored their emotions rather low at intervals throughout the whole surgical process, though their scores also changed during the surgical process. Emotion scores did not decrease after patient education. No differences in patients' emotions were found to result from either of the two different patient education methods.

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

Patient-generated Digital Images after Pediatric Ambulatory Surgery.

PubMed

Miller, Matthew W; Ross, Rachael K; Voight, Christina; Brouwer, Heather; Karavite, Dean J; Gerber, Jeffrey S; Grundmeier, Robert W; Coffin, Susan E

2016-07-06

To describe the use of digital images captured by parents or guardians and sent to clinicians for assessment of wounds after pediatric ambulatory surgery. Subjects with digital images of post-operative wounds were identified as part of an on-going cohort study of infections after ambulatory surgery within a large pediatric healthcare system. We performed a structured review of the electronic health record (EHR) to determine how digital images were documented in the EHR and used in clinical care. We identified 166 patients whose parent or guardian reported sending a digital image of the wound to the clinician after surgery. A corresponding digital image was located in the EHR in only 121 of these encounters. A change in clinical management was documented in 20% of these encounters, including referral for in-person evaluation of the wound and antibiotic prescription. Clinical teams have developed ad hoc workflows to use digital images to evaluate post-operative pediatric surgical patients. Because the use of digital images to support follow-up care after ambulatory surgery is likely to increase, it is important that high-quality images are captured and documented appropriately in the EHR to ensure privacy, security, and a high-level of care.

Patient-Generated Digital Images after Pediatric Ambulatory Surgery

PubMed Central

Ross, Rachael K.; Voight, Christina; Brouwer, Heather; Karavite, Dean J.; Gerber, Jeffrey S.; Grundmeier, Robert W.; Coffin, Susan E.

2016-01-01

Summary Objective To describe the use of digital images captured by parents or guardians and sent to clinicians for assessment of wounds after pediatric ambulatory surgery. Methods Subjects with digital images of post-operative wounds were identified as part of an ongoing cohort study of infections after ambulatory surgery within a large pediatric healthcare system. We performed a structured review of the electronic health record (EHR) to determine how digital images were documented in the EHR and used in clinical care. Results We identified 166 patients whose parent or guardian reported sending a digital image of the wound to the clinician after surgery. A corresponding digital image was located in the EHR in only 121 of these encounters. A change in clinical management was documented in 20% of these encounters, including referral for in-person evaluation of the wound and antibiotic prescription. Conclusion Clinical teams have developed ad hoc workflows to use digital images to evaluate post-operative pediatric surgical patients. Because the use of digital images to support follow-up care after ambulatory surgery is likely to increase, it is important that high-quality images are captured and documented appropriately in the EHR to ensure privacy, security, and a high-level of care. PMID:27452477

Infection Prevention and Control in Pediatric Ambulatory Settings.

PubMed

Rathore, Mobeen H; Jackson, Mary Anne

2017-11-01

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

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.…

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

PubMed

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

2013-02-01

To examine the types and frequencies of oral surgery diagnoses and ambulatory oral surgical treatments during one year period at the Department of Oral Surgery, University Hospital Dubrava in Zagreb, Croatia. Sociodemographic and clinical data on 11680 ambulatory patients, treated between January 1 and of December 31, 2011 were retrieved from the hospital database using a specific protocol. The obtained data were subsequently analyzed in order to assess the frequency of diagnoses and differences in sex and age. The most common ambulatory procedure was tooth extraction (37.67%) and the most common procedure in ambulatory operating room was alveolectomy (57.25%). The test of proportions showed that significantly more extractions (P<0.001) and intraoral incisions (P<0.001) were performed among male patients, whereas significantly more alveolectomies and apicoectomies were performed among female patients (P<0.001). A greater prevalence of periodontal disease was found in patients residing in Zagreb than in patients residing in rural areas. The data from this study may be useful for planning of ambulatory oral surgery services, budgeting, and sustaining quality improvement, enhancing oral surgical curricula, training and education of primary health care doctors and oral surgery specialists, and promoting patients' awareness of the importance of oral health.

The internal medicine clerkship and ambulatory learning experiences: results of the 2010 clerkship directors in internal medicine survey.

PubMed

Shaheen, Amy; Papp, Klara K; Torre, Dario

2013-01-01

Education in the ambulatory setting should be an integral part of undergraduate medical education. However, previous studies have shown education in this setting has been lacking in medical school. Ambulatory education occurs on some internal medicine clerkships. The extent of this education is unclear. The purpose of this survey was to assess the structure, curriculum, assessment methods, and barriers to implementation of ambulatory education on the internal medicine clerkship. An annual survey of institutional members of the Clerkship Directors in Internal Medicine (CDIM) was done in April 2010. The data were anonymous and descriptive statistics were used to summarize responses. Free text results were analyzed using qualitative techniques. The response rate was 75%. The majority of respondents had a required ambulatory component to the clerkship. Ambulatory experiences distinct from the inpatient internal medicine experience were common (46%). Integration with either the inpatient experiences or other departmental clerkships also occurred. The majority of ambulatory educational experiences were with generalists (74%) and/or subspecialists (45%). The most common assessment tool was the National Board of Medical Examiners (NBME) ambulatory shelf exam. Thematic analysis of the question about how practice based learning was taught elicited four major themes: Not taught; taught in the context of learning evidence based medicine; taught while learning chronic disease management with quality improvement; taught while learning about health care finance. Barriers to implementation included lack of faculty and financial resources. There have been significant increases in the amount of time dedicated to ambulatory internal medicine. The numbers of medical schools with ambulatory internal medicine education has increased. Integration of the ambulatory experiences with other clerkships such as family medicine occurs. Curriculum was varied but difficulties with dissemination

A Model for Integrating Ambulatory Surgery Centers Into an Academic Health System Using a Novel Ambulatory Surgery Coordinating Council.

PubMed

Ishii, Lisa; Pronovost, Peter J; Demski, Renee; Wylie, Gill; Zenilman, Michael

2016-06-01

An increasing volume of ambulatory surgeries has led to an increase in the number of ambulatory surgery centers (ASCs). Some academic health systems have aligned with ASCs to create a more integrated care delivery system. Yet, these centers are diverse in many areas, including specialty types, ownership models, management, physician employment, and regulatory oversight. Academic health systems then face challenges in integrating these ASCs into their organizations. Johns Hopkins Medicine created the Ambulatory Surgery Coordinating Council in 2014 to manage, standardize, and promote peer learning among its eight ASCs. The Armstrong Institute for Patient Safety and Quality provided support and a model for this organization through its quality management infrastructure. The physician-led council defined a mission and created goals to identify best practices, uniformly provide the highest-quality patient-centered care, and continuously improve patient outcomes and experience across ASCs. Council members built trust and agreed on a standardized patient safety and quality dashboard to report measures that include regulatory, care process, patient experience, and outcomes data. The council addressed unintentional outcomes and process variation across the system and agreed to standard approaches to optimize quality. Council members also developed a process for identifying future goals, standardizing care practices and electronic medical record documentation, and creating quality and safety policies. The early success of the council supports the continuation of the Armstrong Institute model for physician-led quality management. Other academic health systems can learn from this model as they integrate ASCs into their complex organizations.

Relationships between developmental profiles and ambulatory ability in A follow-up study of preschool children with spastic quadriplegic cerebral palsy.

PubMed

Chen, Chia-Ling; Chen, Chung-Yao; Lin, Keh-Chung; Chen, Kai-Hua; Wu, Ching-Yi; Lin, Chu-Hsu; Liu, Wen-Yu; Hsu, Hung-Chih

2010-01-01

To investigate the follow-up course of developmental profiles in preschool children with spastic quadriplegic (SQ) cerebral palsy (CP) who had varying ambulatory abilities. Forty-eight children with SQ CP between 1 and 5 years old were classified into 2 groups, the ambulatory and non-ambulatory groups, based on Gross Motor Function Classification System (GMFCS) levels during the initial assessment. The developmental profiles, consisting of development quotients (DQs) of 8 domains, were evaluated during the initial assessment and the final assessment one year later. The DQ change index (%) was calculated as 100% X (final DQ-initial DQ)/initial DQ. The DQs of all developmental domains in the non-ambulatory group were lower than those in the ambulatory group on both initial and final assessments (p<0.01). As indicated by the DQ change indices, most DQs in the ambulatory group decreased slightly, whereas those in the non-ambulatory group decreased considerably (p<0.05). Furthermore, fine motor function increased proportionally with age in the ambulatory group, but not in the non-ambulatory group. The DQs of the developmental profiles varied in preschool CP children with different ambulatory abilities. The course of developmental profiles in preschool children with SQ CP evolves with age and relates to the degree of ambulatory function. Knowledge of these developmental profiles may be helpful in understanding, predicting, and managing the developmental problems of these children.

Pediatric ambulatory anesthesia.

PubMed

August, David A; Everett, Lucinda L

2014-06-01

Pediatric patients often undergo anesthesia for ambulatory procedures. This article discusses several common preoperative dilemmas, including whether to postpone anesthesia when a child has an upper respiratory infection, whether to test young women for pregnancy, which children require overnight admission for apnea monitoring, and the effectiveness of nonpharmacological techniques for reducing anxiety. Medication issues covered include the risks of anesthetic agents in children with undiagnosed weakness, the use of remifentanil for tracheal intubation, and perioperative dosing of rectal acetaminophen. The relative merits of caudal and dorsal penile nerve block for pain after circumcision are also discussed. Copyright © 2014 Elsevier Inc. All rights reserved.

Adverse Drug Events in U.S. Adult Ambulatory Medical Care

PubMed Central

Sarkar, Urmimala; López, Andrea; Maselli, Judith H; Gonzales, Ralph

2011-01-01

Objective To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings. Data Source We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys. Study Design Secondary data analysis. Principal Findings An estimated 13.5 million ADE-related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age-specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE-related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]). Conclusions Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices. PMID:21554271

Identifying opportunities to advance practice at a large academic medical center using the ASHP Ambulatory Care Self-Assessment Tool.

PubMed

Martirosov, Amber Lanae; Michael, Angela; McCarty, Melissa; Bacon, Opal; DiLodovico, John R; Jantz, Arin; Kostoff, Diana; MacDonald, Nancy C; Mikulandric, Nancy; Neme, Klodiana; Sulejmani, Nimisha; Summers, Bryant B

2018-05-29

The use of the ASHP Ambulatory Care Self-Assessment Tool to advance pharmacy practice at 8 ambulatory care clinics of a large academic medical center is described. The ASHP Ambulatory Care Self-Assessment Tool was developed to help ambulatory care pharmacists assess how their current practices align with the ASHP Practice Advancement Initiative. The Henry Ford Hospital Ambulatory Care Advisory Group (ACAG) opted to use the "Practitioner Track" sections of the tool to assess pharmacy practices within each of 8 ambulatory care clinics individually. The responses to self-assessment items were then compiled and discussed by ACAG members. The group identified best practices and ways to implement action items to advance ambulatory care practice throughout the institution. Three recommended action items were common to most clinics: (1) identify and evaluate solutions to deliver financially viable services, (2) develop technology to improve patient care, and (3) optimize the role of pharmacy technicians and support personnel. The ACAG leadership met with pharmacy administrators to discuss how action items that were both feasible and deemed likely to have a medium-to-high impact aligned with departmental goals and used this information to develop an ambulatory care strategic plan. This process informed and enabled initiatives to advance ambulatory care pharmacy practice within the system. The ASHP Ambulatory Care Self-Assessment Tool was useful in identifying opportunities for practice advancement in a large academic medical center. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

[Structural development of ambulatory surgical care in the United States of America. What can we learn or apply?].

PubMed

Kraus, T; Wolkener, F; Mieth, M; Möller, J; Büchler, M W

2002-10-01

Expansion of ambulatory surgical care is a major focus in United States health politics. In 1996 a total of 31.5 million ambulatory operations were performed, currently accounting for 45% of yearly procedures. Operations in ophthalmology and gastroenterology are predominant. Ambulatory surgery is organized in different forms: "office-based surgery," "hospital outpatient departments," and "ambulatory surgery centers" (ASC). The numbers of ASCs are rapidly increasing. The current proportion of ASCs is 16% of all operations. The type of ambulatory surgery is primarily defined by payors. Medicare standards are the benchmark for private organizations. Recovery care centers now offer postoperative care beyond the former 23-h threshold. This may lead to a further expanded ASC access. Revenues for ambulatory surgery were so far mostly based on fees for service. The implementation of an outpatient prospective payment system ("OPPS") is planned by Medicare, using fixed package prices within a newly defined ambulatory payment classification ("APC"). The dimension of structural changes could be enormous and possibly be compared with the implementation of DRGs in 1983.

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

PubMed

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

2012-01-01

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

[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. Copyright © 2016 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.

[Intensive care anaesthesia practice in the prison environment. Can a prisoner benefit from ambulatory anaesthesia].

PubMed

Manaouil, C; Montpellier, D; Sannier, O; Defouilloy, C; Radji, M; Jardé, O; Dupont, H

2010-01-01

Ambulatory anaesthesia is an anesthesia allowing the return of the patient home the same day. Even if the ambulatory hospitalization can, in theory, be applied to a prisoner as to every patient, caution is essential in such approach. Every anaesthetist reanimator doctor practicing in public hospitals may give care to patient prisoners while he is far from dominating all features of the prison world and while he must put down his therapeutic indications. The ambulatory anaesthesia in prison environment does not guarantee full security for the patient. Procedures could be set up between hospital complexes, caretakers practicing within penal middle (Unit of Consultation and Ambulatory Care [UCAC]) the prison service and hospital, the prefecture, to identify possible ambulatory interventions for a patient prisoner and to set up all guarantees of patient follow-up care in his return in prison environment. The development of interregional secure hospital units (ISHU) within teaching hospitals, allows an easier realization of interventions to the prisoners, but exists only in seven teaching hospitals in France. Copyright 2009 Elsevier Masson SAS. All rights reserved.

Ambulatory Surgery Has Minimal Impact on Sleep Parameters: A Prospective Observational Trial.

PubMed

Hudson, Arlene J; Walter, Robert J; Flynn, John; Szpisjak, Dale F; Olsen, Cara; Rodgers, Matthew; Capaldi, Vincent F; McDuffie, Brent; Lettieri, Christopher J

2018-04-15

The presence of obstructive sleep apnea (OSA) in ambulatory surgical patients causes significant perioperative concern; however, few data exist to guide clinicians' management decisions. The objective of this study was to measure changes in perioperative sleep parameters among an ambulatory surgery population. This study is a prospective, observational study of ambulatory patients undergoing orthopedic surgery on an extremity. Study subjects completed three unattended home sleep apnea tests: baseline before surgery, the first night after surgery (N1), and third night after surgery (N3). Anesthesia and surgical teams were blinded to study participation and patients received routine perioperative care. Two hundred three subjects were enrolled and 166 completed the baseline home sleep test. Sixty-six (40.0%) had OSA at baseline, 35 patients received a new diagnosis, and 31 patients had a previous diagnosis of OSA. Of those with a previous diagnosis, 20 (64.5%) were compliant with continuous positive airway pressure therapy. Respiratory event index and SpO 2 nadir did not significantly change postoperatively from baseline. Cumulative percentage of time oxygen saturation < 90% significantly increased N1 as compared to baseline for all patients except for those with moderate to severe OSA. Ambulatory surgery had minimal effect on sleep parameters and there was no increase in adverse events among patients with either treated or untreated OSA. Registry: ClinicalTrials.gov; Title: Evaluation of Sleep Disordered Breathing Following Ambulatory Surgery; Identifier: NCT01851798; URL: https://clinicaltrials.gov/ct2/show/study/NCT01851798. © 2018 American Academy of Sleep Medicine.

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

PubMed

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

2018-01-01

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

Office blood pressure or ambulatory blood pressure for the prediction of cardiovascular events.

PubMed

Mortensen, Rikke Nørmark; Gerds, Thomas Alexander; Jeppesen, Jørgen Lykke; Torp-Pedersen, Christian

2017-11-21

To determine the added value of (i) 24-h ambulatory blood pressure relative to office blood pressure and (ii) night-time ambulatory blood pressure relative to daytime ambulatory blood pressure for 10-year person-specific absolute risks of fatal and non-fatal cardiovascular events. A total of 7927 participants were included from the International Database on Ambulatory blood pressure monitoring in relation to Cardiovascular Outcomes. We used cause-specific Cox regression to predict 10-year person-specific absolute risks of fatal and non-fatal cardiovascular events. Discrimination of 10-year outcomes was assessed by time-dependent area under the receiver operating characteristic curve (AUC). No differences in predicted risks were observed when comparing office blood pressure and ambulatory blood pressure. The median difference in 10-year risks (1st; 3rd quartile) was -0.01% (-0.3%; 0.1%) for cardiovascular mortality and -0.1% (-1.1%; 0.5%) for cardiovascular events. The difference in AUC (95% confidence interval) was 0.65% (0.22-1.08%) for cardiovascular mortality and 1.33% (0.83-1.84%) for cardiovascular events. Comparing daytime and night-time blood pressure, the median difference in 10-year risks was 0.002% (-0.1%; 0.1%) for cardiovascular mortality and -0.01% (-0.5%; 0.2%) for cardiovascular events. The difference in AUC was 0.10% (-0.08 to 0.29%) for cardiovascular mortality and 0.15% (-0.06 to 0.35%) for cardiovascular events. Ten-year predictions obtained from ambulatory blood pressure are similar to predictions from office blood pressure. Night-time blood pressure does not improve 10-year predictions obtained from daytime measurements. For an otherwise healthy population sufficient prognostic accuracy of cardiovascular risks can be achieved with office blood pressure. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

Low bone mineral density in ambulatory persons with cerebral palsy? A systematic review.

PubMed

Mus-Peters, Cindy T R; Huisstede, Bionka M A; Noten, Suzie; Hitters, Minou W M G C; van der Slot, Wilma M A; van den Berg-Emons, Rita J G

2018-05-22

Non-ambulatory persons with cerebral palsy are prone to low bone mineral density. In ambulatory persons with cerebral palsy, bone mineral density deficits are expected to be small or absent, but a consensus conclusion is lacking. In this systematic review bone mineral density in ambulatory persons with cerebral palsy (Gross Motor Function Classification Scales I-III) was studied. Medline, Embase, and Web of Science were searched. According to international guidelines, low bone mineral density was defined as Z-score ≤ -2.0. In addition, we focused on Z-score ≤ -1.0 because this may indicate a tendency towards low bone mineral density. We included 16 studies, comprising 465 patients aged 1-65 years. Moderate and conflicting evidence for low bone mineral density (Z-score ≤ -2.0) was found for several body parts (total proximal femur, total body, distal femur, lumbar spine) in children with Gross Motor Function Classification Scales II and III. We found no evidence for low bone mineral density in children with Gross Motor Function Classification Scale I or adults, although there was a tendency towards low bone mineral density (Z-score ≤ -1.0) for several body parts. Although more high-quality research is needed, results indicate that deficits in bone mineral density are not restricted to non-ambulatory people with cerebral palsy. Implications for Rehabilitation Although more high-quality research is needed, including adults and fracture risk assessment, the current study indicates that deficits in bone mineral density are not restricted to non-ambulatory people with CP. Health care professionals should be aware that optimal nutrition, supplements on indication, and an active lifestyle, preferably with weight-bearing activities, are important in ambulatory people with CP, also from a bone quality point-of-view. If indicated, medication and fall prevention training should be prescribed.

[Development of a portable ambulatory ECG monitor based on embedded microprocessor unit].

PubMed

Wang, Da-xiong; Wang, Guo-jun

2005-06-01

To develop a new kind of portable ambulatory ECG monitor. The hardware and software were designed based on RCA-CDP1802. New methods of ECG data compression and feature extraction of QRS complexes were applied to software design. A model for automatic arrhythmia analysis was established for real-time ambulatory ECG Data analysis. Compact, low power consumption and low cost were emphasized in the hardware design. This compact and light-weight monitor with low power consumption and high intelligence was capable of real-time monitoring arrhythmia for more than 48 h. More than ten types of arrhythmia could be detected, only the compressed abnormal ECG data was recorded and could be transmitted to the host if required. The monitor meets the design requirements and can be used for ambulatory ECG monitoring.

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.

Light sensors for objective light measurement in ambulatory polysomnography.

PubMed

Schembri, Rachel; Spong, Jo; Peters, Allison; Rochford, Peter; Wilksch, Philip; O'Donoghue, Fergal J; Greenwood, Kenneth M; Barnes, Maree; Kennedy, Gerard A; Berlowitz, David J

2017-01-01

Ambulatory polysomnography (PSG) does not commonly include an objective measure of light to determine the time of lights off (Loff), and thus cannot be used to calculate important indices such as sleep onset latency and sleep efficiency. This study examined the technical specifications and appropriateness of a prototype light sensor (LS) for use in ambulatory Compumedics Somte PSG.Two studies were conducted. The first examined the light measurement characteristics of the LS when used with a portable PSG device, specifically recording trace range, linearity, sensitivity, and stability. This involved the LS being exposed to varying incandescent and fluorescent light levels in a light controlled room. Secondly, the LS was trialled in 24 home and 12 hospital ambulatory PSGs to investigate whether light levels in home and hospital settings were within the recording range of the LS, and to quantify the typical light intensity reduction at the time of Loff. A preliminary exploration of clinical utility was also conducted. Linearity between LS voltage and lux was demonstrated, and the LS trace was stable over 14 hours of recording. The observed maximum voltage output of the LS/PSG device was 250 mV, corresponding to a maximum recording range of 350 lux and 523 lux for incandescent and fluorescent light respectively. At the time of Loff, light levels were within the recording range of the LS, and on average dropped by 72 lux (9-245) in the home and 76 lux (4-348) in the hospital setting. Results suggest that clinical utility was greatest in hospital settings where patients are less mobile. The LS was a simple and effective objective marker of light level in portable PSG, which can be used to identify Loff in ambulatory PSG. This allows measurement of additional sleep indices and support with clinical decisions.

Ambulatory Pulse Wave Velocity Is a Stronger Predictor of Cardiovascular Events and All-Cause Mortality Than Office and Ambulatory Blood Pressure in Hemodialysis Patients.

PubMed

Sarafidis, Pantelis A; Loutradis, Charalampos; Karpetas, Antonios; Tzanis, Georgios; Piperidou, Alexia; Koutroumpas, Georgios; Raptis, Vasilios; Syrgkanis, Christos; Liakopoulos, Vasilios; Efstratiadis, Georgios; London, Gérard; Zoccali, Carmine

2017-07-01

Arterial stiffness and augmentation of aortic blood pressure (BP) measured in office are known cardiovascular risk factors in hemodialysis patients. This study examines the prognostic significance of ambulatory brachial BP, central BP, pulse wave velocity (PWV), and heart rate-adjusted augmentation index [AIx(75)] in this population. A total of 170 hemodialysis patients underwent 48-hour ambulatory monitoring with Mobil-O-Graph-NG during a standard interdialytic interval and followed-up for 28.1±11.2 months. The primary end point was a combination of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. Secondary end points included: (1) all-cause mortality; (2) cardiovascular mortality; and (3) a combination of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, resuscitation after cardiac arrest, coronary revascularization, or hospitalization for heart failure. During follow-up, 37(21.8%) patients died and 46(27.1%) had cardiovascular events. Cumulative freedom from primary end point was similar for quartiles of predialysis-systolic BP (SBP), 48-hour peripheral-SBP, and central-SBP, but was progressively longer for increasing quartiles for 48-hour peripheral-diastolic BP and central-diastolic BP and shorter for increasing quartiles of 48-hour central pulse pressure (83.7%, 71.4%, 69.0%, 62.8% [log-rank P =0.024]), PWV (93.0%, 81.0%, 57.1%, 55.8% [log-rank P <0.001]), and AIx(75) (88.4%, 66.7%, 69.0%, 62.8% [log-rank P =0.014]). The hazard ratios for all-cause mortality, cardiovascular mortality, and the combined outcome were similar for quartiles of predialysis-SBP, 48-hour peripheral-SBP, and central-SBP, but were increasing with higher ambulatory PWV and AIx(75). In multivariate analysis, 48-hour PWV was the only vascular parameter independently associated with the primary end point (hazard ratios, 1.579; 95% confidence intervals, 1.187-2.102). Ambulatory PWV, AIx(75), and central pulse pressure are associated with increased

Ambulatory blood pressure and adherence monitoring: diagnosing pseudoresistant hypertension.

PubMed

Burnier, Michel; Wuerzner, Gregoire

2014-01-01

A small proportion of the treated hypertensive population consistently has a blood pressure greater than 140/90 mm Hg despite a triple therapy including a diuretic, a calcium channel blocker, and a blocker of the renin-angiotensin system. According to guidelines, these patients have so-called resistant hypertension. The prevalence of this clinical condition is higher in tertiary than primary care centers and often is associated with chronic kidney disease, diabetes, obesity, and sleep apnea syndrome. Exclusion of pseudoresistant hypertension using ambulatory or home blood pressure monitoring is a crucial step in the investigation of patients with resistant hypertension. Thus, among the multiple factors to consider when investigating patients with resistant hypertension, ambulatory blood pressure monitoring should be performed very early. Among other factors to consider, physicians should investigate patient adherence to therapy, assess the adequacy of treatment, exclude interfering factors, and, finally, look for secondary forms of hypertension. Poor adherence to therapy accounts for 30% to 50% of cases of resistance to therapy depending on the methodology used to diagnose adherence problems. This review discusses the clinical factors implicated in the pathogenesis of resistant hypertension with a particular emphasis on pseudoresistance, drug adherence, and the use of ambulatory blood pressure monitoring for the diagnosis and management of resistant hypertension.

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.

Unanticipated hospital admission in pediatric patients with congenital heart disease undergoing ambulatory noncardiac surgical procedures.

PubMed

Yuki, Koichi; Koutsogiannaki, Sophia; Lee, Sandra; DiNardo, James A

2018-05-18

An increasing number of surgical and nonsurgical procedures are being performed on an ambulatory basis in children. Analysis of a large group of pediatric patients with congenital heart disease undergoing ambulatory procedures has not been undertaken. The objective of this study was to characterize the profile of children with congenital heart disease who underwent noncardiac procedures on an ambulatory basis at our institution, to determine the incidence of adverse cardiovascular and respiratory adverse events, and to determine the risk factors for unscheduled hospital admission. This is a retrospective study of children with congenital heart disease who underwent noncardiac procedures on an ambulatory basis in a single center. Using the electronic preoperative anesthesia evaluation form, we identified 3010 patients with congenital heart disease who underwent noncardiac procedures of which 1028 (34.1%) were scheduled to occur on an ambulatory basis. Demographic, echocardiographic and functional status data, cardiovascular and respiratory adverse events, and reasons for postprocedure admission were recorded. Univariable analysis was conducted. The unplanned hospital admission was 2.7% and univariable analysis demonstrated that performance of an echocardiogram within 6 mo of the procedure and procedures performed in radiology were associated with postoperative admission. Cardiovascular adverse event incidence was 3.9%. Respiratory adverse event incidence was 1.8%. Ambulatory, noncomplex procedures can be performed in pediatric patients with congenital heart disease and good functional status with a relatively low unanticipated hospital admission rate. © 2018 John Wiley & Sons Ltd.

Opening ambulatory surgery centers and stone surgery rates in health care markets.

PubMed

Hollingsworth, John M; Krein, Sarah L; Birkmeyer, John D; Ye, Zaojun; Kim, Hyungjin Myra; Zhang, Yun; Hollenbeck, Brent K

2010-09-01

Ambulatory surgery centers deliver surgical care more efficiently than hospitals but may increase overall procedure use and adversely affect competing hospitals. Motivated by these concerns we evaluated how opening of an ambulatory surgery center impacts stone surgery use in a health care market and assessed the effect of its opening on the patient mix at nearby hospitals. In a 100% sample of outpatient surgery from Florida we measured annual stone surgery use between 1998 and 2006. We used multiple regression to determine if the rate of change in use differed between markets, defined by the hospital service area, without and with a recently opened ambulatory surgery center. Stone surgery use increased an average of 11 procedures per 100,000 individuals per year (95% CI 1-20, p <0.001) after an ambulatory surgery center opened in a hospital service area. Four years after opening the relative increase in the stone surgery rate was approximately 64% higher (95% CI 27 to 102) in hospital service areas where a center opened vs hospital service areas without a center. These market level increases in surgery were not associated with decreased surgical volume at competing hospitals and the absolute change in patient disease severity treated at nearby hospitals was small. While opening of an ambulatory surgery center did not appear to have an overly detrimental effect on competing hospitals, it led to a significant increase in the population based rate of stone surgery in the hospital service area. Possible explanations are the role of physician financial incentives and unmet surgical demand. 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Emergent risk factors associated with eyeball loss and ambulatory vision loss after globe injuries.

PubMed

Hyun Lee, Seung; Ahn, Jae Kyoun

2010-07-01

The objective of this study was to evaluate risk factors associated with eyeball loss and ambulatory vision loss on emergent examination of patients with ocular trauma. We reviewed the medical records of 1,875 patients hospitalized in a single tertiary referral center between January 2003 and December 2007. Emergent examinations included a history of trauma, elapsed time between injury and hospital arrival, visible intraocular tissues, and initial visual acuity (VA) using a penlight. The main outcome measures were ocular survival and ambulatory vision survival (>20/200) at 1 year after trauma using univariate and multivariate regression analysis. The ocular trauma scores were significantly higher in open globe injuries than in closed globe injuries (p < 0.01). In open globe injuries, initial VA less than light perception (LP) and a history of golf ball injury were the significant risk factors associated with eyeball loss. Elapsed time more than 12 hours and visible intraocular tissues were the significant risk factors associated with ambulatory vision loss. The most powerful predictor of eyeball loss and ambulatory vision loss was eyeball rupture. In closed globe injuries, there were no significant risk factors of eyeball loss, whereas initial vision less than LP and the presence of relative afferent pupillary defect were the significant risk factors associated with ambulatory vision loss. An initial VA less than LP using a penlight, a history of golf ball injury, and elapsed time more than 12 hours between ocular trauma and hospital arrival were associated with eyeball loss and ambulatory vision loss. Physicians should bear these factors in mind so that they can more effectively counsel patients with such injuries.

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

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

PubMed

Saukaitis, C A

1994-09-01

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

Accreditation of ambulatory facilities.

PubMed

Urman, Richard D; Philip, Beverly K

2014-06-01

With the continued growth of ambulatory surgical centers (ASC), the regulation of facilities has evolved to include new standards and requirements on both state and federal levels. Accreditation allows for the assessment of clinical practice, improves accountability, and better ensures quality of care. In some states, ASC may choose to voluntarily apply for accreditation from a recognized organization, but in others it is mandated. Accreditation provides external validation of safe practices, benchmarking performance against other accredited facilities, and demonstrates to patients and payers the facility's commitment to continuous quality improvement. Copyright © 2014 Elsevier Inc. All rights reserved.

[Evaluation of a teaching ambulatory module of respiratory diseases in the undergraduate medical curriculum].

PubMed

Leiva R, Isabel; Bitran C, Marcela; Saldías P, Fernando

2012-05-01

As the focus of healthcare provision shifts towards ambulatory care, increasing attention must now be given to develop opportunities for clinical teaching in this setting. To assess teacher and students' views about the strengths and weaknesses of real and simulated patient interactions for teaching undergraduate students clinical skills in the ambulatory setting. Fourth-year medical students were exposed in a systematic way, during two weeks, to real and simulated patients in an outpatient clinic, who presented common respiratory problems, such as asthma, chronic obstructive pulmonary disease, smoking and sleep apnea syndrome. After the clinical interview, students received feedback from the tutor and their peers. The module was assessed interviewing the teachers and evaluating the results qualitatively. Students evaluated the contents and quality of teaching at the end of the rotation. Tutors identified the factors that facilitate ambulatory teaching. These depended on the module design, resources and patient care, of characteristics of students and their participation, leadership and interaction with professors. They also identified factors that hamper teaching activities such as availability of resources, student motivation and academic recognition. Most students evaluated favorably the interaction with real and simulated patients in the ambulatory setting. Teaching in the ambulatory setting was well evaluated by students and teachers. The use of qualitative methodology allowed contrasting the opinions of teachers and students.

Measuring safety culture in the ambulatory setting: the safety attitudes questionnaire--ambulatory version.

PubMed

Modak, Isitri; Sexton, J Bryan; Lux, Thomas R; Helmreich, Robert L; Thomas, Eric J

2007-01-01

Provider attitudes about issues pertinent to patient safety may be related to errors and adverse events. We know of no instruments that measure safety-related attitudes in the outpatient setting. To adapt the safety attitudes questionnaire (SAQ) to the outpatient setting and compare attitudes among different types of providers in the outpatient setting. We modified the SAQ to create a 62-item SAQ-ambulatory version (SAQ-A). Patient care staff in a multispecialty, academic practice rated their agreement with the items using a 5-point Likert scale. Cronbach's alpha was calculated to determine reliability of scale scores. Differences in SAQ-A scores between providers were assessed using ANOVA. Of the 409 staff, 282 (69%) returned surveys. One hundred ninety (46%) surveys were included in the analyses. Cronbach's alpha ranged from 0.68 to 0.86 for the scales: teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions, and stress recognition. Physicians had the least favorable attitudes about perceptions of management while managers had the most favorable attitudes (mean scores: 50.4 +/- 22.5 vs 72.5 +/- 19.6, P < 0.05; percent with positive attitudes 18% vs 70%, respectively). Nurses had the most positive stress recognition scores (mean score 66.0 +/- 24.0). All providers had similar attitudes toward teamwork climate, safety climate, job satisfaction, and working conditions. The SAQ-A is a reliable tool for eliciting provider attitudes about the ambulatory work setting. Attitudes relevant to medical error may differ among provider types and reflect behavior and clinic operations that could be improved.

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

Learning From Errors in Ambulatory Pediatrics

DTIC Science & Technology

2005-01-01

355 Learning from Errors in Ambulatory Pediatrics Julie J. Mohr, Carole M. Lannon, Kathleen A. Thoma, Donna Woods, Eric J. Slora, Richard C...for Healthcare Research and Quality (AHRQ) as part of the University of North Carolina (UNC) Center for Education and Research on Therapeutics...CERTs), in partnership with the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings (PROS) Network. Purpose: Learning from Errors

Feasibility and validity of computerized ambulatory monitoring in stroke patients.

PubMed

Johnson, E I; Sibon, I; Renou, P; Rouanet, F; Allard, M; Swendsen, J

2009-11-10

Computerized ambulatory monitoring provides real-time assessments of clinical outcomes in natural contexts, and it has been increasingly applied in recent years to investigate symptom expression in a wide range of disorders. The purpose of this study was to examine the feasibility and validity of this data collection strategy with adult stroke patients. Forty-eight individuals (75% of the contacted sample) agreed to participate in the current study and were instructed to complete electronic interviews using a personal digital assistant 5 times per day over a 1-week period. More than 80% of programmed assessments were completed by the sample, and no evidence was found for fatigue effects. Expected patterns of associations were observed among daily life variables, and data collected through ambulatory monitoring were significantly correlated with standard clinic-based measures of similar constructs. Support was found for the feasibility and validity of computerized ambulatory monitoring with stroke patients. The application of these novel methods with stroke patients should provide complementary information that is inaccessible to standard hospital-based assessments and permit increased understanding of the significance of clinical results and test scores for daily life experience.

Ambulatory vital signs in the workup of pulmonary embolism using a standardized 3-minute walk test.

PubMed

Amin, Qamar; Perry, Jeffrey J; Stiell, Ian G; Mohapatra, Subhra; Alsadoon, Abdulaziz; Rodger, Marc

2015-05-01

Diagnosing pulmonary embolism can be difficult given its highly variable clinical presentation. Our objective was to determine whether a decrease in oxygen saturation or an increase in heart rate while ambulating could be used as an objective tool in the diagnosis of pulmonary embolism. This was a two-site tertiary-care-centre prospective cohort study that enrolled adult emergency department or thrombosis clinic patients with suspected or newly confirmed pulmonary embolism. Patients were asked to participate in a standardized 3-minute walk test, which assessed ambulatory heart rate and ambulatory oxygen saturation. The primary outcome was pulmonary embolism. We enrolled 114 patients, including 30 with pulmonary embolism (26.3%). A ≥2% absolute decrease in ambulatory oxygen saturation and an ambulatory change in heart rate >10 beats per minute (BPM) were significantly associated with pulmonary embolism. An ambulatory heart rate change of >10 BPM had a sensitivity of 96.6% (95% confidence interval [CI] 83.3 to 99.4) and a specificity of 31.0% (95% CI 22.1 to 45.0) for pulmonary embolism. A ≥2% absolute decrease ambulatory oxygen saturation had a sensitivity of 80.2% (95% CI 62.7 to 90.5) and a specificity of 39.3% (95% CI 29.5 to 50.0) for pulmonary embolism. The combination of both variables yielded a sensitivity of 100.0% (95% CI 87.0 to 100.0) and a specificity of 11.0% (95% CI 6.6 to 21.0). In summary, our study found that an ambulatory heart rate change of >10 BPM or a ≥2% absolute decrease in ambulatory oxygen saturation from baseline during a standardized 3-minute walk test are highly correlated with pulmonary embolism. Although the findings appear promising, neither of these variables can currently be recommended as a screening tool for pulmonary embolism until larger prospective studies examine their performance either alone or with pre-existing rules.

Pets are ‘risky business’ for patients undergoing continuous ambulatory peritoneal dialysis

PubMed Central

Al-Fifi, Yahya Salim Yahya; Sathianathan, Chris; Murray, Brenda-Lee; Alfa, Michelle J

2013-01-01

The authors report the first case in Manitoba of a patient undergoing continuous ambulatory peritoneal dialysis who experienced three successive infections with Pasteurella multocida and Capnocytophaga species over an eight-month period. These zoonotic infections were believed to originate from contact with the patient’s household pets. To prevent such infections, the authors recommend the development and implementation of hygiene guidelines outlining the risks associated with owning domestic pets for continuous ambulatory peritoneal dialysis patients. PMID:24421840

[The health care structure law as a political public health reform in ambulatory and day surgery].

PubMed

Sorgatz, H

1994-01-01

The statutory opening of hospitals for ambulatory surgery can't without more ado be derived from the health-care reform which came into force on the 1st of January 1993. From the genesis of this reform it can be understood that the field of ambulatory surgery has been integrated just shortly before its legislation into the outlines of the health-care reform. As a consequence the hospitals are obliged to follow the principle "ambulatory before stationary" even in the stationary field. In this way the strict separation between the two fields (ambulatory and stationary) will be overcome to a great extent. Taking into consideration the further changes brought by the health-care reform in the stationary field new ranges of action for hospitals, with their chances but also their risks, have to be expected.

Ambulatory Status Protects against Venous Thromboembolism in Acute Mild Ischemic Stroke Patients.

PubMed

Sisante, Jason-Flor V; Abraham, Michael G; Phadnis, Milind A; Billinger, Sandra A; Mittal, Manoj K

2016-10-01

Ischemic stroke patients are at high risk (up to 18%) for venous thromboembolism. We conducted a retrospective cross-sectional study to understand the predictors of acute postmild ischemic stroke patient's ambulatory status and its relationship with venous thromboembolism, hospital length of stay, and in-hospital mortality. We identified 522 patients between February 2006 and May 2014 and collected data about patient demographics, admission NIHSS (National Institutes of Health Stroke Scale), venous thromboembolism prophylaxis, ambulatory status, diagnosis of venous thromboembolism, and hospital outcomes (length of stay, mortality). Chi-square test, t-test and Wilcoxon rank-sum test, and binary logistic regression were used for statistical analysis as appropriate. A total of 61 (11.7%), 48 (9.2%), and 23 (4.4%) mild ischemic stroke patients developed venous thromboembolism, deep venous thrombosis, and pulmonary embolism, respectively. During hospitalization, 281 (53.8%) patients were ambulatory. Independent predictors of in-hospital ambulation were being married (OR 1.64, 95% CI 1.10-2.49), being nonreligious (OR 2.19, 95% CI 1.34-3.62), admission NIHSS (per unit decrease in NIHSS; OR 1.62, 95% CI 1.39-1.91), and nonuse of mechanical venous thromboembolism prophylaxis (OR 1.62, 95% CI 1.02-2.61). After adjusting for confounders, ambulatory patients had lower rates of venous thromboembolism (OR .47, 95% CI .25-.89), deep venous thrombosis (OR .36, 95% CI .17-.73), prolonged length of hospital stay (OR .24, 95% CI .16-.37), and mortality (OR .43, 95% CI .21-.84). Our findings suggest that for hospitalized acute mild ischemic stroke patients, ambulatory status is an independent predictor of venous thromboembolism (specifically deep venous thrombosis), hospital length of stay, and in-hospital mortality. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Ambulatory Status Protects Against Venous Thromboembolism in Acute Mild Ischemic Stroke Patients

PubMed Central

Sisante, Jason-Flor V.; Abraham, Michael G.; Phadnis, Milind A.; Billinger, Sandra A.; Mittal, Manoj K.

2016-01-01

Introduction Ischemic stroke patients are at high risk (up to 18%) for venous thromboembolism. We conducted a retrospective cross-sectional study to understand the predictors of acute post-mild ischemic stroke patient’s ambulatory status and its relationship with venous thromboembolism, hospital length of stay, and in-hospital mortality. Methods We identified 522 patients between February 2006 and May 2014 and collected data about patient demographics, admission NIHSS, venous thromboembolism prophylaxis, ambulatory status, diagnosis of venous thromboembolism, and hospital outcomes (length of stay, mortality). Chi-square tests, t-test and Wilcoxon Ranks Sum tests, and binary logistic regression were used for statistical analysis as appropriate. Results A total of 61 (11.7%), 48 (9.2%), and 23 (4.4%) mild ischemic stroke patients developed venous thromboembolism, deep venous thrombosis, and pulmonary embolism, respectively. During hospitalization, 281 (53.8%) patients were ambulatory. Independent predictors of in-hospital ambulation were being married (OR 1.64, 95% CI 1.10–2.49), being non-religious (OR 2.19, 95% CI 1.34–3.62), admission NIHSS (per unit decrease in NIHSS; OR 1.62, 95% CI 1.39–1.91), and non-usage of mechanical venous thromboembolism prophylaxis (OR 1.62, 95% CI 1.02–2.61). After adjusting for confounders, ambulatory patients had lower rates of venous thromboembolism (OR 0.47, 95% CI 0.25–0.89), deep venous thrombosis (OR 0.36, 95% CI 0.17–0.73), prolonged length of hospital stay (OR 0.24, 95% CI 0.16–0.37), and mortality (OR 0.43, 95% CI 0.21–0.84). Conclusions Our findings suggest that for hospitalized acute mild ischemic stroke patients, ambulatory status is an independent predictor of venous thromboembolism (specifically deep venous thrombosis), hospital length of stay, and in-hospital mortality. PMID:27423367

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

PubMed

Debernardi, G; Borgogna, E

1975-01-01

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

Ambulatory oral surgery: 1-year experience with 11 680 patients from Zagreb district, Croatia

PubMed Central

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

2013-01-01

Aim To examine the types and frequencies of oral surgery diagnoses and ambulatory oral surgical treatments during one year period at the Department of Oral Surgery, University Hospital Dubrava in Zagreb, Croatia. Methods Sociodemographic and clinical data on 11 680 ambulatory patients, treated between January 1 and of December 31, 2011 were retrieved from the hospital database using a specific protocol. The obtained data were subsequently analyzed in order to assess the frequency of diagnoses and differences in sex and age. Results The most common ambulatory procedure was tooth extraction (37.67%) and the most common procedure in ambulatory operating room was alveolectomy (57.25%). The test of proportions showed that significantly more extractions (P < 0.001) and intraoral incisions (P < 0.001) were performed among male patients, whereas significantly more alveolectomies and apicoectomies were performed among female patients (P < 0.001). A greater prevalence of periodontal disease was found in patients residing in Zagreb than in patients residing in rural areas. Conclusion The data from this study may be useful for planning of ambulatory oral surgery services, budgeting, and sustaining quality improvement, enhancing oral surgical curricula, training and education of primary health care doctors and oral surgery specialists, and promoting patients’ awareness of the importance of oral health. PMID:23444246

Ambulatory tuberculosis treatment in post-Semashko health care systems needs supportive financing mechanisms.

PubMed

Kohler, S; Asadov, D A; Bründer, A; Healy, S; Khamraev, A K; Sergeeva, N; Tinnemann, P

2014-12-01

The tuberculosis (TB) control strategy in the Republic of Karakalpakstan, Uzbekistan, is being changed to decentralised out-patient care for most TB patients by the Government of Uzbekistan, in collaboration with the international medical humanitarian organisation Médecins Sans Frontières. Ambulatory treatment of both drug-susceptible and drug-resistant TB from the first day of treatment has been recommended since 2011. Out-patient treatment of TB from the beginning of treatment was previously prohibited. However, the current Uzbek health financing system, which evolved from the Soviet Semashko model, offers incentives that work against the adoption of ambulatory TB treatment. Based on the 'Comprehensive TB Care for All' programme implemented in Karakalpakstan, we describe how existing policies for the allocation of health funds complicate the scale-up of ambulatory-based management of TB.

Burden of norovirus gastroenteritis in the ambulatory setting--United States, 2001-2009.

PubMed

Gastañaduy, Paul A; Hall, Aron J; Curns, Aaron T; Parashar, Umesh D; Lopman, Benjamin A

2013-04-01

Gastroenteritis remains an important cause of morbidity in the United States. The burden of norovirus gastroenteritis in ambulatory US patients is not well understood. Cause-specified and cause-unspecified gastroenteritis emergency department (ED) and outpatient visits during July 2001-June 2009 were extracted from MarketScan insurance claim databases. By using cause-specified encounters, time-series regression models were fitted to predict the number of unspecified gastroenteritis visits due to specific pathogens other than norovirus. Model residuals were used to estimate norovirus visits. MarketScan rates were extrapolated to the US population to estimate national ambulatory visits. During 2001-2009, the estimated annual mean rates of norovirus-associated ED and outpatient visits were 14 and 57 cases per 10 000 persons, respectively, across all ages. Rates for ages 0-4, 5-17, 18-64, and ≥65 years were 38, 10, 12, and 15 ED visits per 10 000 persons, respectively, and 233, 85, 35, and 54 outpatient visits per 10 000 persons, respectively. Norovirus was estimated to cause 13% of all gastroenteritis-associated ambulatory visits, with ~50% of such visits occurring during November-February. Nationally, norovirus contributed to approximately 400 000 ED visits and 1.7 million office visits annually, resulting in $284 million in healthcare charges. Norovirus is a substantial cause of gastroenteritis in the ambulatory setting.

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.

Hospital ambulatory medicine: A leading strategy for Internal Medicine in Europe.

PubMed

Corbella, Xavier; Barreto, Vasco; Bassetti, Stefano; Bivol, Monica; Castellino, Pietro; de Kruijf, Evert-Jan; Dentali, Francesco; Durusu-Tanriöver, Mine; Fierbinţeanu-Braticevici, Carmen; Hanslik, Thomas; Hojs, Radovan; Kiňová, Soňa; Lazebnik, Leonid; Livčāne, Evija; Raspe, Matthias; Campos, Luis

2018-04-13

Addressing the current collision course between growing healthcare demands, rising costs and limited resources is an extremely complex challenge for most healthcare systems worldwide. Given the consensus that this critical reality is unsustainable from staff, consumer, and financial perspectives, our aim was to describe the official position and approach of the Working Group on Professional Issues and Quality of Care of the European Federation of Internal Medicine (EFIM), for encouraging internists to lead a thorough reengineering of hospital operational procedures by the implementation of innovative hospital ambulatory care strategies. Among these, we include outpatient and ambulatory care strategies, quick diagnostic units, hospital-at-home, observation units and daycare hospitals. Moving from traditional 'bed-based' inpatient care to hospital ambulatory medicine may optimize patient flow, relieve pressure on hospital bed availability by avoiding hospital admissions and shortening unnecessary hospital stays, reduce hospital-acquired complications, increase the capacity of hospitals with minor structural investments, increase efficiency, and offer patients a broader, more appropriate and more satisfactory spectrum of delivery options. Copyright © 2018. Published by Elsevier B.V.

Anticoagulation management in the ambulatory surgical setting.

PubMed

Eisenstein, Diana Hill

2012-04-01

Many people receiving maintenance anticoagulation therapy require surgery each year in ambulatory surgery centers. National safety organizations focus attention toward improving anticoagulation management, and the American College of Chest Physicians has established guidelines for appropriate anticoagulation management to balance the risk of thromboembolism when warfarin is discontinued with the risk of bleeding when anticoagulation therapy is maintained. The guidelines recommend that patients at high or moderate risk for thromboembolism should be bridged with subcutaneous low-molecular-weight heparin or IV unfractionated heparin with the interruption of warfarin, and low-risk patients may require subcutaneous low-molecular-weight heparin or no bridging with the interruption of warfarin. The guidelines recommend the continuation of warfarin for patients who are undergoing minor dermatologic or dental procedures or cataract removal. The literature reveals, however, that there is not adequate adherence to these recommendations and guidelines. Management of anticoagulation therapy by a nurse practitioner may improve compliance and safety in ambulatory surgery centers. Copyright © 2012 AORN, Inc. Published by Elsevier Inc. All rights reserved.

The association between the availability of ambulatory care and non-emergency treatment in emergency medicine departments: a comprehensive and nationwide validation.

PubMed

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

2013-05-01

To quantify dynamic availability of ambulatory care, and to examine possible associations with non-emergency treatments in emergency departments (EDs). Longitudinal data from the Taiwan National health Insurance Research Database were used to evaluate 749,584 emergency-medicine cases occurring between 2005 and 2010 according to a modified New York University algorithm. Multivariable-cumulative-logistic-regression analysis with generalized estimating-equation methods was used to determine associations between availability of ambulatory care and the urgency of patients' medical needs during ED visits. More than half (53.04%) of the ED visits that were evaluated in our study were classified as non-emergencies, and over half of these occurred despite a high availability of ambulatory care facilities (median > 96%). Compared with patients in areas with a low availability of ambulatory care, patients in areas of medium to high availability showed approximately 0.8 times lower odds ratios for associations with non-emergency ED visits. Non-emergency ED visits may be reduced by increasing the availability of ambulatory care facilities in areas with deficits in the availability of such facilities. However, increasing the availability of ambulatory care by raising the number of available ambulatory care physicians or the number of ambulatory care facilities may not reduce non-emergency ED visits in areas with medium to high availability of ambulatory care facilities. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Prevalence, Treatment, and Control Rates of Conventional and Ambulatory Hypertension Across 10 Populations in 3 Continents.

PubMed

Melgarejo, Jesus D; Maestre, Gladys E; Thijs, Lutgarde; Asayama, Kei; Boggia, José; Casiglia, Edoardo; Hansen, Tine W; Imai, Yutaka; Jacobs, Lotte; Jeppesen, Jørgen; Kawecka-Jaszcz, Kalina; Kuznetsova, Tatiana; Li, Yan; Malyutina, Sofia; Nikitin, Yuri; Ohkubo, Takayoshi; Stolarz-Skrzypek, Katarzyna; Wang, Ji-Guang; Staessen, Jan A

2017-07-01

Hypertension is a major global health problem, but prevalence rates vary widely among regions. To determine prevalence, treatment, and control rates of hypertension, we measured conventional blood pressure (BP) and 24-hour ambulatory BP in 6546 subjects, aged 40 to 79 years, recruited from 10 community-dwelling cohorts on 3 continents. We determined how between-cohort differences in risk factors and socioeconomic factors influence hypertension rates. The overall prevalence was 49.3% (range between cohorts, 40.0%-86.8%) for conventional hypertension (conventional BP ≥140/90 mm Hg) and 48.7% (35.2%-66.5%) for ambulatory hypertension (ambulatory BP ≥130/80 mm Hg). Treatment and control rates for conventional hypertension were 48.0% (33.5%-74.1%) and 38.6% (10.1%-55.3%) respectively. The corresponding rates for ambulatory hypertension were 48.6% (30.5%-71.9%) and 45.6% (18.6%-64.2%). Among 1677 untreated subjects with conventional hypertension, 35.7% had white coat hypertension (23.5%-56.2%). Masked hypertension (conventional BP <140/90 mm Hg and ambulatory BP ≥130/80 mm Hg) occurred in 16.9% (8.8%-30.5%) of 3320 untreated subjects who were normotensive on conventional measurement. Exclusion of participants with diabetes mellitus, obesity, hypercholesterolemia, or history of cardiovascular complications resulted in a <9% reduction in the conventional and 24-hour ambulatory hypertension rates. Higher social and economic development, measured by the Human Development Index, was associated with lower rates of conventional and ambulatory hypertension. In conclusion, high rates of hypertension in all cohorts examined demonstrate the need for improvements in prevention, treatment, and control. Strategies for the management of hypertension should continue to not only focus on preventable and modifiable risk factors but also consider societal issues. © 2017 American Heart Association, Inc.

The Ambulatory Long-Block: An Accreditation Council for Graduate Medical Education (ACGME) Educational Innovations Project (EIP)

PubMed Central

Schauer, Daniel P.; Diers, Tiffiny; Mathis, Bradley R.; Neirouz, Yvette; Boex, James R.; Rouan, Gregory W.

2008-01-01

Introduction Historical bias toward service-oriented inpatient graduate medical education experiences has hindered both resident education and care of patients in the ambulatory setting. Aim Describe and evaluate a residency redesign intended to improve the ambulatory experience for residents and patients. Setting Categorical Internal Medicine resident ambulatory practice at the University of Cincinnati Academic Health Center. Program Description We created a year-long continuous ambulatory group-practice experience separated from traditional inpatient responsibilities called the long block as an Accreditation Council for Graduate Medical Education Educational Innovations Project. The practice adopted the Chronic Care Model and residents received extensive instruction in quality improvement and interprofessional teams. Program Evaluation The long block was associated with significant increases in resident and patient satisfaction as well as improvement in multiple quality process and outcome measures. Continuity and no-show rates also improved. Discussion An ambulatory long block can be associated with improvements in resident and patient satisfaction, quality measures, and no-show rates. Future research should be done to determine effects of the long block on education and patient care in the long term, and elucidate which aspects of the long block most contribute to improvement. PMID:18612718

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

PubMed

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

2013-04-01

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

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…

[Ambulatory pediatrics: a challenge].

PubMed

Ransy, V; Gevers, B; Landsberg, M

2006-01-01

Ambulatory paediatrics in University hospitals has remarkably evolved during the past decade, along with technological progress and the current need for undelayed information and attention; demand for hospital medical advice increases consequently, either directly in outpatients wards or indirectly by phone or e-mails. Specific medico-social aspects linked essentially to populations' migration, poverty, chronic stress and family splitting are regularly encountered. Hospital architecture and adequacy of medical and nursing staff must both be adjusted to these changing medical demands including medical teaching. We now face the ever-growing challenge of providing an adequate management of actual medico-psycho-social aspects and integrating up-to-date paediatrics in our daily practices.

Participation restrictions in ambulatory amyotrophic lateral sclerosis patients: Physical and psychological factors.

PubMed

Van Groenestijn, Annerieke C; Schröder, Carin D; Kruitwagen-Van Reenen, Esther T; Van Den Berg, Leonard H; Visser-Meily, Johanna M A

2017-11-01

The aim of this study was to assess the prevalence of participation restrictions in ambulatory patients with amyotrophic lateral sclerosis (ALS) and to identify physical and psychological contributory factors. In this cross-sectional study, self-reported participation restrictions of 72 ambulatory ALS patients were assessed using the social health status dimension (SIPSOC) of the Sickness Impact Profile (SIP-68). Associations between SIPSOC and physical functioning, psychological factors, and demographic factors were analyzed using hierarchical regression analyses. Ninety-two percent of the patients reported participation restrictions; 54.9% could be explained by physical functioning; psychological factors accounted for 8.1% of the variance. Lung capacity, functional mobility, fatigue, and helplessness were independently associated with participation restrictions. Ambulatory ALS patients have participation restrictions, which may be influenced if early ALS care is directed toward lung capacity, functional mobility, fatigue, and feelings of helplessness. Muscle Nerve 56: 912-918, 2017. © 2017 Wiley Periodicals, Inc.

Left ventricular mass predicted by a single reading of ambulatory blood pressure in essential hypertension.

PubMed

Ohmori, S; Matsumura, K; Kajioka, T; Fukuhara, M; Abe, I; Fujishima, M

2000-07-01

The spectral power of heart rate variability has been shown to be negatively correlated with left ventricular mass (LVM), suggesting the contribution of left ventricular hypertrophy to autonomic dysfunction in essential hypertension. However, a simultaneous assessment of autonomic function and ambulatory blood pressure in relation to LVM has not been carried out. The objective of the present study was to elucidate the synergistic effects of ambulatory blood pressure and autonomic nerve activity on the heart. We enrolled 25 ambulant patients with untreated essential hypertension (9 men and 16 women; mean age 50.6 +/- 2.0 years). The ambulatory blood pressure and heart rate variability were simultaneously monitored every 30 min for 24 h. The spectral power of high-frequency (HF: 0.15 to 0.4 Hz) and low-frequency (LF: 0.05 to 0.15 Hz) bands were measured, and the ratio of LF to HF (LF/HF) was calculated. LF/HF and HF were used as indexes of sympathetic and parasympathetic activities, respectively. LVM was determined by echocardiography. Both the average daytime and nighttime systolic ambulatory blood pressures significantly correlated with the LVM index (r= 0.644, p< 0.001; and r= 0.428, p< 0.05; respectively), although there was no such correlation with the clinic blood pressures. In contrast, a single reading of ambulatory systolic blood pressure measured when LF/HF reached a maximum value was significantly correlated with the LVM index independently of age and sex (partial r= 0.484, p< 0.05). These results suggest that the ambulatory systolic blood pressure during increases in the activity of the sympathetic nervous system is able to infer LVM in essential hypertension.

Variability in opioid prescribing for children undergoing ambulatory surgery in the United States.

PubMed

Van Cleve, William C; Grigg, Eliot B

2017-09-01

We attempted to describe the opioid prescribing patterns for ambulatory pediatric surgery in the United States from 2007 to 2014. Retrospective database review. Operating room ambulatory encounters as determined by the Truven Health Marketscan Commercial Claims and Encounters database. A total of 929,874 ambulatory surgical encounters were identified in patients <18years of age and, of these, 439,286 encounters generated an analgesic prescription. N/A MEASUREMENTS: The analgesic prescription was described in terms of the type of opioid along with the inclusion of acetaminophen and/or NSAIDs. The probability of receiving a post-operative analgesic prescription increased with age, ranging from 18.2% of infants to 71.7% of teens. Acetaminophen with codeine (APAP/C) was the most common drug for infants (63.8%), while acetaminophen with hydrocodone (APAP/H) was the most common analgesic prescription for teens (53.6%). APAP/C and APAP/H were the predominant drugs used for all procedure types. Substantial variability in analgesic prescribing at the level of the procedure performed, both in terms of the probability of receiving a prescription and in which drugs were prescribed. We observed significant age and procedure-based variability in opioid prescribing following pediatric ambulatory surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

A validation of the Mobil O Graph (version 12) ambulatory blood pressure monitor.

PubMed

Jones, C R; Taylor, K; Chowienczyk, P; Poston, L; Shennan, A H

2000-08-01

To assess the clinical accuracy of the Mobil O Graph (version 12) ambulatory blood pressure monitor in an adult population. The accuracy of the device was assessed by predefined criteria (British Hypertension Society, BHS) in 85 subjects recruited from the patients and staff in a teaching hospital. A series of same-arm sequential blood pressure measurements were taken: first two observers taking simultaneous mercury readings, followed by a reading with the Mobil O Graph ambulatory monitor. A total of seven readings were taken from each subject in the sitting position. The data were then analysed according to the BHS protocol and the criteria of the Association for the Advancement of Medical Instrumentation (AAMI). The Mobil O Graph ambulatory monitor fulfilled the criteria of the BHS protocol, achieving a grade B for systolic blood pressure (SBP) and a grade A for diastolic blood pressure (DBP). The mean differences were -2+/-8 mmHg for SBP and -2+/-7 mmHg for DBP. The device therefore also passed the AAMI standard (the mean to be within 5+/-8 mmHg). The Mobil O Graph ambulatory monitor performed in a satisfactory manner according to the BHS and the AAMI criteria and can therefore be recommended for clinical use in the general population.

Ambulatory cardiovascular activity and hostility ratings in women with chronic posttraumatic stress disorder.

PubMed

Beckham, Jean C; Flood, Amanda M; Dennis, Michelle F; Calhoun, Patrick S

2009-02-01

The objective of the current study is to evaluate the relationship between hostility and ambulatory cardiovascular activity in women with and without posttraumatic stress disorder (PTSD). One hundred and one women completed 24 hours of ambulatory monitoring and standardized diagnostic and hostility measures. Generalized estimating equations analysis was used to examine the effects of group and hostility factor scores (hostile beliefs, overt hostility, and covert hostility) on ambulatory heart rate (AHR) and ambulatory systolic (ASBP) and diastolic (ADBP) blood pressure. After controlling for covariates, there was an interaction between PTSD and both hostile beliefs and overt hostility for AHR. Increases in hostility were associated with greater increases in heart rate among women with PTSD relative to those without PTSD. There was a similar interaction between hostile beliefs and group for ADBP. Increased AHR and blood pressure have been linked to poor cardiovascular outcomes in nonpsychiatric populations. Individuals with PTSD display increased hostility, a construct that has also been linked to poorer cardiovascular outcomes. Increases in hostile beliefs were associated with a greater increase in ADBP among women with PTSD as compared with control subjects. These data suggest that PTSD might in part moderate the relationship between hostility and cardiovascular outcomes.

[Incidence of surgical site infection in ambulatory surgery: results of the INCISCO surveillance network in 1999-2000].

PubMed

Sewonou, A; Rioux, C; Golliot, F; Richard, L; Massault, P P; Johanet, H; Cherbonnel, G; Botherel, A H; Farret, D; Astagneau, P

2002-04-01

To estimate the incidence of surgical-site infections (SSI) in ambulatory surgery and to identify risk factors based on the surveillance network INCISO in 1999-2000. Annually, during a three-month period, each surgical ward had to include 200 consecutive operations. Patients were surveyed over the month following surgery. For each patient, data including peri-operative factors, type of procedure and SSI occurrence were collected on a standardized form by a surgical staff committed for the study. Of the 5,183 patients who underwent an ambulatory surgery, the SSI incidence ratio was 0.4% (95% CI [0.3-0.7]). Orthopedic, gynecologic/obstetrics, head and neck, skin and soft tissues surgery accounted for 83% of all ambulatory procedures. 93% of patients belonged to the 0 risk category of the National Nosocomial Infections Surveillance system (NNIS) index. Emergency, age, american anesthesia risk score (ASA), Altemeier wound class, and procedure duration were not found to be risk factors for SSI in ambulatory surgery. Based on these surveillance data, infectious risk was low in ambulatory surgery and was not associated with known SSI risk factors.

85. INTERIOR VIEW, DETAIL, HEAD HOUSE, FIRST FLOOR AMBULATORY, WOOD ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

85. INTERIOR VIEW, DETAIL, HEAD HOUSE, FIRST FLOOR AMBULATORY, WOOD FLOOR SHOWING ORIGINAL AND REPLACED PANELS, LOOKING SOUTHWEST - Timberline Lodge, Timberline Trail, Government Camp, Clackamas County, OR

[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.

An Ambulatory Medical Education Program for Internal Medicine Residents.

ERIC Educational Resources Information Center

Wones, Robert G.; And Others

1987-01-01

An ambulatory medicine program for university hospital clinic residents was found to be effective in improving students' knowledge, enhancing attitudes toward the clinic, and improving performance of influenza vaccinations. No adverse program effects were found. (MSE)

Ambulatory monitoring of activities and motor symptoms in Parkinson's disease.

PubMed

Zwartjes, Daphne G M; Heida, Tjitske; van Vugt, Jeroen P P; Geelen, Jan A G; Veltink, Peter H

2010-11-01

Ambulatory monitoring of motor symptoms in Parkinsons disease (PD) can improve our therapeutic strategies, especially in patients with motor fluctuations. Previously published monitors usually assess only one or a few basic aspects of the cardinal motor symptoms in a laboratory setting. We developed a novel ambulatory monitoring system that provides a complete motor assessment by simultaneously analyzing current motor activity of the patient (e.g. sitting, walking) and the severity of many aspects related to tremor, bradykinesia, and hypokinesia. The monitor consists of a set of four inertial sensors. Validity of our monitor was established in seven healthy controls and six PD patients treated with deep brain stimulation (DBS) of the subthalamic nucleus. Patients were tested at three different levels of DBS treatment. Subjects were monitored while performing different tasks, including motor tests of the Unified Parkinsons Disease Rating Scale (UPDRS). Output of the monitor was compared to simultaneously recorded videos. The monitor proved very accurate in discriminating between several motor activities. Monitor output correlated well with blinded UPDRS ratings during different DBS levels. The combined analysis of motor activity and symptom severity by our PD monitor brings true ambulatory monitoring of a wide variety of motor symptoms one step closer..

Watsu approach for improving spasticity and ambulatory function in hemiparetic patients with stroke.

PubMed

Chon, Seung Chul; Oh, Duck Won; Shim, Jae Hun

2009-06-01

This study reports the effect of Watsu as rehabilitation method for hemiparetic patients with stroke. Watsu consisted of 40 treatment sessions for 8 weeks, delivered underwater or at water surface level, it applied in three patients. Outcome measures included tools for assessing spasticity and ambulatory function. All patients showed decreased scores in the TAS and RVGA after Watsu application. Watsu was helpful in controlling spasticity and improving ambulatory function of the patients with hemiparesis.

Ambulatory diffuse optical tomography and multimodality physiological monitoring system for muscle and exercise applications

NASA Astrophysics Data System (ADS)

Hu, Gang; Zhang, Quan; Ivkovic, Vladimir; Strangman, Gary E.

2016-09-01

Ambulatory diffuse optical tomography (aDOT) is based on near-infrared spectroscopy (NIRS) and enables three-dimensional imaging of regional hemodynamics and oxygen consumption during a person's normal activities. Although NIRS has been previously used for muscle assessment, it has been notably limited in terms of the number of channels measured, the extent to which subjects can be ambulatory, and/or the ability to simultaneously acquire synchronized auxiliary data such as electromyography (EMG) or electrocardiography (ECG). We describe the development of a prototype aDOT system, called NINscan-M, capable of ambulatory tomographic imaging as well as simultaneous auxiliary multimodal physiological monitoring. Powered by four AA size batteries and weighing 577 g, the NINscan-M prototype can synchronously record 64-channel NIRS imaging data, eight channels of EMG, ECG, or other analog signals, plus force, acceleration, rotation, and temperature for 24+ h at up to 250 Hz. We describe the system's design, characterization, and performance characteristics. We also describe examples of isometric, cycle ergometer, and free-running ambulatory exercise to demonstrate tomographic imaging at 25 Hz. NINscan-M represents a multiuse tool for muscle physiology studies as well as clinical muscle assessment.

Predictors of At-Home Arterial Oxygen Desaturation Events in Ambulatory Surgical Patients.

PubMed

Biddle, Chuck; Elam, Charles; Lahaye, Laura; Kerr, Gordon; Chubb, Laura; Verhulst, Brad

2016-11-02

Little is known about the early recovery phase occurring at-home after anesthesia and surgery in ambulatory surgical patients. We studied quantitative oximetry and quality-of-life metrics in the first 48 hours after same-day orthopedic surgery examining the association between the recovery metrics and specific patient and procedural factors. We used the STOP-Bang score to quantify patient risk for obstructive sleep apnea in 50 adult patients at 2 centers using continuous portable oximetry and patient journaling. Parametric statistical procedures were used to assess relationships among patient and procedural factors and desaturation events. Higher STOP-Bang scores were predictive of the number and duration of desaturation events below mild and severe thresholds for arterial oxygen saturation during their first 48 hours after discharge from ambulatory surgery. Older patients and patients with higher BMI in particular were at an increased risk of mild and severe arterial oxygen desaturation. Using a home CPAP reduced the number of desaturation events. Of interest, taking opiate analgesics decreased the number of desaturation events. Given the absence of systematic research of early ambulatory anesthesia/surgery recovery at home and concerns of postoperative respiratory events, our results have clear implications for patient safety. Our results imply that screening based on noninvasive STOP-Bang scores may allow for suggestions for recovery from ambulatory surgery, such as encouraging patients with high scores to use home CPAP and aggressive education regarding use of opiates.

Estimated financial savings associated with health information exchange and ambulatory care referral.

PubMed

Frisse, Mark E; Holmes, Rodney L

2007-12-01

Data and financial models based on an operational health information exchange suggest that health care delivery costs can be reduced by making clinical data available at the time of care in urban emergency departments. Reductions are the result of decreases in laboratory and radiographic tests, fewer admissions for observation, and lower overall emergency department costs. The likelihood of reducing these costs depends on the extent to which clinicians alter their workflow and take into account information available through the exchange from other institutions prior to initiating a treatment plan. Far greater savings can be realized in theory by identifying individuals presenting to emergency departments whose acute and long-term care needs are more suitably addressed at lower costs in ambulatory settings or medical homes. These alternative ambulatory settings can more effectively address the chronic care needs of those who receive most of their care in emergency departments. To support a shift from emergency room care to clinic care, health care information available through the health information exchange must be made available in both emergency department and ambulatory care settings. If practice workflow and patient behavior can be changed, a more effective and efficient care delivery system will be made possible through the secure exchange of clinical information across regional settings. These projections support the case for the financial viability of regional health information exchanges and motivate participation of hospitals and ambulatory care organizations-particularly in urban settings.

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

PubMed

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

2001-03-01

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

Body mass index in ambulatory cerebral palsy patients.

PubMed

Feeley, Brian T; Gollapudi, Kiran; Otsuka, Norman Y

2007-05-01

Malnutrition is a common problem in children with cerebral palsy. Although malnutrition is often recognized in patients with severe cerebral palsy, it can be unrecognized in less severely affected patients. The consequences of malnutrition are serious, and include decreased muscle strength, poor immune status, and depressed cerebral functioning. Low body mass index has been used as a marker for malnutrition. The purpose of this study was to determine which patients in an ambulatory cerebral palsy patient population were at risk for low body mass index. A retrospective chart review was performed on 75 patients. Age, sex, height, weight, type of cerebral palsy, and functional status [gross motor functional classification system (GMFCS) level] was recorded from the chart. Descriptive statistics with bivariate and multivariate regression analyses were performed. Thirty-eight boys and 37 girls with an average age of 8.11 years were included in the study. Unique to our patient population, all cerebral palsy patients were independent ambulators. Patients with quadriplegic cerebral palsy had a significantly lower body mass index than those with diplegic and hemiplegic cerebral palsy. Patients with a GMFCS III had significantly lower body mass index than those with GMFCS I and II. When multivariate regression analysis to control for age and sex was performed, low body mass index remained associated with quadriplegic cerebral palsy and GMFCS III. Malnutrition is a common health problem in patients with cerebral palsy, leading to significant morbidity in multiple organ systems. We found that in an ambulatory cerebral palsy population, patients with lower functional status or quadriplegia had significantly lower body mass index, suggesting that even highly functioning ambulatory cerebral palsy patients are at risk for malnutrition.

Anesthesia for Ambulatory Pediatric Surgery in Sub-Saharan Africa: A Pilot Study in Burkina Faso.

PubMed

Kabré, Yvette B; Traoré, Idriss S S; Kaboré, Flavien A R; Ki, Bertille; Traoré, Alain I; Ouédraogo, Isso; Bandré, Emile; Wandaogo, Albert; Ouédraogo, Nazinigouba

2017-02-01

Long surgical wait times and limited hospital capacity are common obstacles to surgical care in many countries in Sub-Saharan Africa (SSA). Introducing ambulatory surgery might contribute to a solution to these problems. The purpose of this study was to evaluate the safety and feasibility of introducing ambulatory surgery into a pediatric hospital in SSA. This is a cross-sectional descriptive study that took place over 6 months. It includes all patients assigned to undergo ambulatory surgery in the Pediatric University Hospital in Ouagadougou, Burkina Faso. Eligibility criteria for the ambulatory surgery program included >1 year of age, American Society of Anesthesiologists (ASA) 1 status, surgery with a low risk of bleeding, lasting <90 minutes, and with an expectation of mild to moderate postoperative pain. The family had to live within 1 hour of the hospital and be available by telephone. During the study period, a total of 1250 patients underwent surgery, of whom 515 were elective cases; 115 of these met the criteria for ambulatory surgery; 103 patients, with an average age of 59.74 ± 41.57 months, actually underwent surgery. The principal indications for surgery were inguinal (62) and umbilical (47) hernias. All patients had general anesthesia with halothane. Sixty-five percent also received regional or local anesthesia consisting of caudal block in 79.23% or nerve block in 20.77%. The average duration of surgery was 33 ± 17.47 minutes. No intraoperative complications were noted. All the patients received acetaminophen and a nonsteroidal anti-inflammatory drug in the recovery room. Twelve (11.7%) patients had complications in recovery, principally nausea and vomiting. Eight (7.8%) patients were admitted to the hospital. No serious complications were associated with ambulatory surgery. Its introduction could possibly be a solution to improving pediatric surgical access in low-income countries.

Relationships of muscle strength and bone mineral density in ambulatory children with cerebral palsy.

PubMed

Chen, C-L; Lin, K-C; Wu, C-Y; Ke, J-Y; Wang, C-J; Chen, C-Y

2012-02-01

This work explores the relationships of muscle strength and areal bone mineral density (aBMD) in ambulatory children with cerebral palsy (CP). The knee extensor strength, but not motor function, was related to aBMD. Thus, muscle strength, especially antigravity muscle strength, was more associated with aBMD in these children than motor function. Muscle strength is related to bone density in normal children. However, no studies have examined these relationships in ambulatory children with CP. This work explores the relationships of muscle strength and aBMD in ambulatory children with CP. Forty-eight ambulatory children with spastic CP, aged 5-15 years, were classified into two groups based on Gross Motor Function Classification System levels: I (n = 28) and II (n = 20). Another 31 normal development (ND) children were recruited as the comparison group for the aBMD. Children with CP underwent assessments of growth, lumbar and distal femur aBMD, Gross Motor Function Measure-66 (GMFM-66), and muscle strength of knee extensor and flexor by isokinetic dynamometer. The distal femur aBMD, but not lumbar aBMD, was lower in children with CP than in ND children (p < 0.05). Children with level I had greater knee flexor strength and GMFM-66 scores than those with level II (p < 0.001). However, the knee extensor strength and distal femur and lumbar aBMD did not differ between two groups. Regression analysis revealed the weight and knee extensor strength, but not GMFM-66 scores, were related positively to the distal femur and lumbar aBMD (adjusted r (2) = 0.56-0.65, p < 0.001). These results suggest the muscle strength, especially antigravity muscle strength, were more associated with the bone density of ambulatory children with CP than motor function. The data may allow clinicians for early identifying the ambulatory CP children of potential low bone density.

Aortic Stiffness, Ambulatory Blood Pressure, and Predictors of Response to Antihypertensive Therapy in Hemodialysis.

PubMed

Georgianos, Panagiotis I; Agarwal, Rajiv

2015-08-01

Arterial stiffness is associated with elevated blood pressure (BP), but it is unclear whether it also makes hypertension more resistant to treatment. Among hypertensive dialysis patients, this study investigated whether aortic stiffness determines ambulatory BP and predicts its improvement with therapy. Post hoc analysis of the Hypertension in Hemodialysis Patients Treated With Atenolol or Lisinopril (HDPAL) trial. 179 hypertensive hemodialysis patients with echocardiographic left ventricular hypertrophy. Baseline aortic pulse wave velocity (PWV). Baseline and treatment-induced change in 44-hour ambulatory BP at 3, 6, and 12 months. Aortic PWV was assessed with an echocardiographic-Doppler technique (ACUSON Cypress, Siemens Medical), and 44-hour interdialytic ambulatory BP monitoring was performed with a Spacelabs 90207 monitor. Mean baseline aortic PWV was 7.6±2.7 (SD) m/s. Overall treatment-induced changes in ambulatory systolic BP (SBP) were -15.6±20.4, -18.9±22.5, and -20.0±19.7 mmHg at 3, 6, and 12 months. Changes in SBP were no different among tertiles of baseline PWV. Aortic PWV was associated directly with baseline ambulatory SBP and pulse pressure (PP) and inversely with diastolic BP (DBP). After adjustment for several cardiovascular risk factors, each 1-m/s higher PWV was associated with 1.34-mm Hg higher baseline SBP (β=1.34±0.46; P=0.004) and 1.02-mm Hg higher PP (β=1.02±0.33; P=0.002), whereas the association with DBP was no longer significant. Baseline PWV did not predict treatment-induced changes in SBP (Wald test, P=0.3) and DBP (Wald test, P=0.7), but was a predictor of an overall improvement in PP during follow-up (Wald test, P=0.03). Observational design; predominantly black patients were studied. Because aortic PWV is not a predictor of treatment-induced change in ambulatory BP among hypertensive dialysis patients, it indicates that among these patients, hypertension can be controlled successfully regardless of aortic stiffness

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

NASA Technical Reports Server (NTRS)

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

2011-01-01

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

[Results of Longo's stapled hemorrhoidectomy in ambulatory surgery for grade III-IV hemorrhoids].

PubMed

Zaragozá, Cristóbal; García Fadrique, Alfonso; Castaño, Sergio; Villalba, Raúl; Bruna Esteban, Marcos; Redondo Cano, Carlos

2007-03-01

We prospectively evaluated the results of stapled hemorrhoidectomy for grade III-IV hemorrhoids in the ambulatory setting. Eighty-five consecutive patients with grade III-IV hemorrhoids, treated with the stapled technique with PPH01 in the Ambulatory Surgery Service of the General Hospital of Valencia were studied. Symptomatic, ASA I-II patients who agreed to undergo ambulatory surgery (vehicle, an accompanying adult, address with telephone, elevator, and basic hygiene conditions) were included. Thirty-nine percent were women and 61% were men, with a mean age of 47.6 years. A total of 85.9% had grade IV hemorrhoids and 14.1% had grade III. The average surgical time was 29.81+/- 12 minutes with a mean length of hospital stay of 168.88 +/- 88 minutes. Surgical complications consisted of 16 hemorrhages of the staple line (18.8%) and five hemorrhages due to mucous tear (5.9%). During the first 8 days the most frequent complication was pain (45.9%); only 7.1% of the patients required analgesia with opiates, and one patient required admission for 24 hours for analgesic purposes. Bleeding occurred in 10 patients, five of whom reported slight bleeding on defecation that stopped spontaneously; the remaining five required admission for 24 hours after surgical revision. Nine patients (10.6%) were admitted to the hospital for 24 hours, three due to intraoperative hemorrhage, five due to postoperative hemorrhage and one due to pain. A second intervention was required in 8.2%. Stapled hemorrhoidectomy can be applied in an ambulatory regime. Although technically simple with a short learning curve, this technique is not free of complications. Suitable patient selection and adequate perioperative information are indispensable for the ambulatory management of this disorder.

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.

New antithrombotic agents in the ambulatory setting.

PubMed

Gibbs, Neville M; Weightman, William M; Watts, Stephen A

2014-12-01

Many patients presenting for surgical or other procedures in an ambulatory setting are taking new antiplatelet or anticoagulant agents. This review assesses how the novel features of these new agents affect the management of antithrombotic therapy in the ambulatory setting. There have been very few studies investigating the relative risks of continuing or ceasing new antithrombotic agents. Recent reviews indicate that the new antithrombotic agents offer greater efficacy or ease of administration but are more difficult to monitor or reverse. They emphasize the importance of assessing the bleeding risk of the procedure, the thrombotic risk if the agent is ceased, and patient factors that increase the likelihood of bleeding. The timing of cessation of the agent, if required, depends on its pharmacokinetics and patients' bleeding risks. Patients at high risk of thrombotic complications may require bridging therapy. Once agreed upon, the perioperative plan should be made clear to all involved. As there are few clinical studies to guide management, clinicians must make rational decisions in relation to continuing or ceasing new antithrombotic agents. This requires knowledge of their pharmacokinetics, and a careful multidisciplinary assessment of the relative thrombotic and bleeding risks in individual patients.

Comparison of ambulatory blood pressure monitoring and office blood pressure measurements in obese children and adolescents.

PubMed

Renda, Rahime

2018-04-01

Obesity in adults has been related to hypertension and abnormal nocturnal dipping of blood pressure, which are associated with poor cardiovascular and renal outcomes. Here, we aimed to resolve the relationship between the degree of obesity, the severity of hypertension and dipping status on ambulatory blood pressure in obese children. A total 72 patients with primary obesity aged 7 to 18 years (mean: 13.48 ± 3.25) were selected. Patients were divided into three groups based on body mass index (BMİ) Z-score. Diagnosis and staging of ambulatory hypertension based on 24-h blood pressure measurements, obtained from ambulatory blood pressure monitoring. Based on our ambulatory blood pressure data, 35 patients (48.6%) had hypertension, 7 (20%) had ambulatory prehypertension, 21 (60%) had hypertension, and 7 patients (20%) had severe ambulatory hypertension. There was a significant relationship between severity of hypertension and the degree of obesity (p < 0.05). Thirty-one patients (88.6%) had isolated nighttime hypertension, and 53 patients (73.6%) were non-dippers. All systolic blood pressure results and loads were similar between groups. Diastolic and mean arterial blood pressure levels during the night, diastolic blood pressure loads, and heart rate during the day were significantly higher in Group 3 (p < 0.05). Nocturnal non-dipping was not associated with severity of obesity. Obesity was associated with severity of hypertension, higher diastolic blood pressure at night, mean arterial pressure at night, diastolic blood pressure loads and heart rate at day. Increase in BMI Z-score does not a significant impact on daytime blood pressure and nocturnal dipping status.

Patient Satisfaction with Kimbrough Ambulatory Care Center

DTIC Science & Technology

1997-02-01

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

Technical and clinical view on ambulatory assessment in Parkinson's disease.

PubMed

Hobert, M A; Maetzler, W; Aminian, K; Chiari, L

2014-09-01

With the progress of technologies of recent years, methods have become available that use wearable sensors and ambulatory systems to measure aspects of--particular axial--motor function. As Parkinson's disease (PD) can be considered a model disorder for motor impairment, a significant number of studies have already been performed with these patients using such techniques. In general, motion sensors such as accelerometers and gyroscopes are used, in combination with lightweight electronics that do not interfere with normal human motion. A fundamental advantage in comparison with usual clinical assessment is that these sensors allow a more quantitative, objective, and reliable evaluation of symptoms; they have also significant advantages compared to in-lab technologies (e.g., optoelectronic motion capture) as they allow long-term monitoring under real-life conditions. In addition, based on recent findings particularly from studies using functional imaging, we learned that non-motor symptoms, specifically cognitive aspects, may be at least indirectly assessable. It is hypothesized that ambulatory quantitative assessment strategies will allow users, clinicians, and scientists in the future to gain more quantitative, unobtrusive, and everyday relevant data out of their clinical evaluation and can also be designed as pervasive (everywhere) and intensive (anytime) tools for ambulatory assessment and even rehabilitation of motor and (partly) non-motor symptoms in PD. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

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

PubMed

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

2018-01-01

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

Pediatric ambulatory care sensitive conditions: Birth cohorts and the socio-economic gradient.

PubMed

Roos, Leslie L; Dragan, Roxana; Schroth, Robert J

2017-09-14

This study examines the socio-economic gradient in utilization and the risk factors associated with hospitalization for four pediatric ambulatory care sensitive conditions (dental conditions, asthma, gastroenteritis, and bacterial pneumonia). Dental conditions, where much care is provided by dentists and insurance coverage varies among different population segments, present special issues. A population registry, provider registry, physician ambulatory claims, and hospital discharge abstracts from 28 398 children born in 2003-2006 in urban centres in Manitoba, Canada were the main data sources. Physician visits and hospitalizations were compared across neighbourhood income groupings using rank correlations and logistic regressions. Very strong relationships between neighbourhood income and utilization were highlighted. Additional variables - family on income assistance, mother's age at first birth, breastfeeding - helped predict the probability of hospitalization. Despite the complete insurance coverage (including visits to dentists and physicians and for hospitalizations) provided, receiving income assistance was associated with higher probabilities of hospitalization. We found a socio-economic gradient in utilization for pediatric ambulatory care sensitive conditions, with higher rates of ambulatory visits and hospitalizations in the poorest neighbourhoods. Insurance coverage which varies between different segments of the population complicates matters. Providing funding for dental care for Manitobans on income assistance has not prevented physician visits or intensive treatment in high-cost facilities, specifically treatment under general anesthesia. When services from one type of provider (dentist) are not universally insured but those from another type (physician) are, using rates of hospitalization to indicate problems in the organization of care seems particularly difficult.

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

PubMed

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

2017-09-15

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

Separate aftereffects of morning and evening exercise on ambulatory blood pressure in prehypertensive men.

PubMed

Brito, Leandro C; Rezende, Rafael A; Mendes, Caroline; Silva-Junior, Natan D; Tinucci, Taís; Cipolla-Neto, José; de Moraes Forjaz, Cláudia L

2018-01-01

Clinic postexercise hypotension (PEH) is different after aerobic exercise performed in the morning and in the evening. Thus, ambulatory PEH should also differ after exercises conducted at different times of day. However, because of the circadian pattern of blood pressure (BP), ambulatory PEH should be assessed considering a control condition. Thus, this study was designed to verify the effects of morning and evening exercises on postexercise ambulatory BP averages and circadian parameters by comparing responses obtained at each time of day after an exercise and a control session. Thirteen prehypertensive men underwent four sessions (randomized order): two in the morning (9 am) and two in the evening (6:30 pm). At each time of day, a control (C) and an exercise (E: cycle ergometer 45 min, 50% VO2peak) sessions were performed. After the sessions, an ambulatory BP and heart rate (HR) monitoring was started for 24 h. Paired t-test or Wilcoxon Signed Rank Test were used to compare the E and the C sessions at each time of day. In the morning, 24 h, daytime and nighttime HR were higher after the E than the C session. In the evening, nighttime systolic BP (116±11 vs. 120±10 mmHg, P=0.04) and rate pressure product (7981±1294 vs. 8583±1523 mmHg.bpm, P=0.04), as well as MESOR (128±11 vs. 130±10 mmHg, P=0.03) were lower in the E than the C session. In prehypertensive men, morning exercise increased ambulatory HR, while evening exercise decreased nighttime BP and cardiac work, reducing the MESOR of systolic BP.

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

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. © 2011 National Association for Healthcare Quality.

Measuring hot flash phenomenonology using ambulatory prospective digital diaries

PubMed Central

Fisher, William I.; Thurston, Rebecca C.

2016-01-01

Objective This study provides the description, protocol, and results from a novel prospective ambulatory digital hot flash phenomenon diary. Methods This study included 152 midlife women with daily hot flashes who completed an ambulatory electronic hot flash diary continuously for the waking hours of 3 consecutive days. In this diary, women recorded their hot flashes and accompanying characteristics and associations as the hot flashes occurred. Results Self-reported hot flash severity on the digital diaries indicated that the majority of hot flashes were rated as mild (41.3%) or moderate (43.7%). Severe (13.1%) and very severe (1.8%) hot flashes were less common. Hot flash bother ratings were rated as mild (43%), or moderate (33.5%), with fewer hot flashes reported bothersome (17.5%) or very bothersome (6%). The majority of hot flashes were reported as occurring on the on the face (78.9%), neck (74.7%), and chest (61.3%). Prickly skin was reported concurrently with 32% of hot flashes, 7% with anxiety and 5% with nausea. A novel finding, 38% of hot flashes were accompanied by a premonitory aura. Conclusion A prospective electronic digital hot flash diary allows for a more precise quantitation of hot flashes while overcoming many of the limitations of commonly employed retrospective questionnaires and paper diaries. Unique insights into the phenomenology, loci and associated characteristics of hot flashes were obtained using this device. The digital hot flash phenomenology diary is recommended for future ambulatory studies of hot flashes as a prospective measure of the hot flash experience. PMID:27404030

Measuring hot flash phenomenonology using ambulatory prospective digital diaries.

PubMed

Fisher, William I; Thurston, Rebecca C

2016-11-01

This study provides the description, protocol, and results from a novel prospective ambulatory digital hot flash phenomenon diary. This study included 152 midlife women with daily hot flashes who completed an ambulatory electronic hot flash diary continuously for the waking hours of three consecutive days. In this diary, women recorded their hot flashes and accompanying characteristics and associations as the hot flashes occurred. Self-reported hot flash severity on the digital diaries indicated that the majority of hot flashes were rated as mild (41.3%) or moderate (43.7%). Severe (13.1%) and very severe (1.8%) hot flashes were less common. Hot flash bother ratings were rated as mild (43%), or moderate (33.5%), with fewer hot flashes reported bothersome (17.5%) or very bothersome (6%). The majority of hot flashes were reported as occurring on the face (78.9%), neck (74.7%), and chest (61.3%). Of all reported hot flashes, 32% occurred concurrently with prickly skin, 7% with anxiety, and 5% with nausea. A novel finding from the study was that 38% of hot flashes were accompanied by a premonitory aura. A prospective electronic digital hot flash diary allows for a more precise quantitation of hot flashes while overcoming many of the limitations of commonly used retrospective questionnaires and paper diaries. Unique insights into the phenomenology, loci, and associated characteristics of hot flashes were obtained using this device. The digital hot flash phenomenology diary is recommended for future ambulatory studies of hot flashes as a prospective measure of the hot flash experience.

[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.

Internet-based monitoring and benchmarking in ambulatory surgery centers.

PubMed

Bovbjerg, V E; Olchanski, V; Zimberg, S E; Green, J S; Rossiter, L F

2000-08-01

Each year the number of surgical procedures performed on an outpatient basis increases, yet relatively little is known about assessing and improving quality of care in ambulatory surgery. Conventional methods for evaluating outcomes, which are based on assessment of inpatient services, are inadequate in the rapidly changing, geographically dispersed field of ambulatory surgery. Internet-based systems for improving outcomes and establishing benchmarks may be feasible and timely. Eleven freestanding ambulatory surgery centers (ASCs) reported process and outcome data for 3,966 outpatient surgical procedures to an outcomes monitoring system (OMS), during a demonstration period from April 1997 to April 1999. ASCs downloaded software and protocol manuals from the OMS Web site. Centers securely submitted clinical information on perioperative process and outcome measures and postoperative patient telephone interviews. Feedback to centers ranged from current and historical rates of surgical and postsurgical complications to patient satisfaction and the adequacy of postsurgical pain relief. ASCs were able to successfully implement the data collection protocols and transmit data to the OMS. Data security efforts were successful in preventing the transmission of patient identifiers. Feedback reports to ASCs were used to institute changes in ASC staffing, patient care, and patient education, as well as for accreditation and marketing. The demonstration also pointed out shortcomings in the OMS, such as the need to simplify hardware and software installation as well as data collection and transfer methods, which have been addressed in subsequent OMS versions. Internet-based benchmarking for geographically dispersed outpatient health care facilities, such as ASCs, is feasible and likely to play a major role in this effort.

What matters to low-income patients in ambulatory care facilities?

PubMed

DeLia, Derek; Hall, Allyson; Prinz, Timothy; Billings, John

2004-09-01

Poor, uninsured, and minority patients depend disproportionately on hospital outpatient departments (OPDs) and freestanding health centers for ambulatory care. These providers confront significant challenges, including limited resources, greater demand for services, and the need to improve quality and patient satisfaction. The authors use a survey of patients in OPDs and health centers in New York City to determine which aspects of the ambulatory care visit have the greatest influence on patients' overall site evaluation. The personal interaction between patients and physicians, provider continuity, and the general cleanliness/appearance of the facility stand out as high priorities. Access to services and interactions with other facility staff are of significant, although lesser, importance. These findings suggest ways to restructure the delivery of care so that it is more responsive to the concerns of low-income patients.

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

Using Ambulatory Voice Monitoring to Investigate Common Voice Disorders: Research Update

PubMed Central

Mehta, Daryush D.; Van Stan, Jarrad H.; Zañartu, Matías; Ghassemi, Marzyeh; Guttag, John V.; Espinoza, Víctor M.; Cortés, Juan P.; Cheyne, Harold A.; Hillman, Robert E.

2015-01-01

Many common voice disorders are chronic or recurring conditions that are likely to result from inefficient and/or abusive patterns of vocal behavior, referred to as vocal hyperfunction. The clinical management of hyperfunctional voice disorders would be greatly enhanced by the ability to monitor and quantify detrimental vocal behaviors during an individual’s activities of daily life. This paper provides an update on ongoing work that uses a miniature accelerometer on the neck surface below the larynx to collect a large set of ambulatory data on patients with hyperfunctional voice disorders (before and after treatment) and matched-control subjects. Three types of analysis approaches are being employed in an effort to identify the best set of measures for differentiating among hyperfunctional and normal patterns of vocal behavior: (1) ambulatory measures of voice use that include vocal dose and voice quality correlates, (2) aerodynamic measures based on glottal airflow estimates extracted from the accelerometer signal using subject-specific vocal system models, and (3) classification based on machine learning and pattern recognition approaches that have been used successfully in analyzing long-term recordings of other physiological signals. Preliminary results demonstrate the potential for ambulatory voice monitoring to improve the diagnosis and treatment of common hyperfunctional voice disorders. PMID:26528472

Ambulatory surgery center market share and rates of outpatient surgery in the elderly.

PubMed

Hollenbeck, Brent K; Hollingsworth, John M; Dunn, Rodney L; Zaojun Ye; Birkmeyer, John D

2010-12-01

Relative to outpatient surgery in hospital settings, ambulatory surgery centers (ASCs) are more efficient and associated with a lower cost per case. However, these facilities may also spur higher overall procedure utilization and thus lead to greater overall health care costs. The authors used the State Ambulatory Surgery Database from the State of Florida to identify Medicare-aged patients undergoing 4 common ambulatory procedures in 2006, including knee arthroscopy, cystoscopy, cataract removal, and colonoscopy. Hospital service areas (HSAs) were characterized according to ASC market share, that is, the proportion of residents undergoing outpatient surgery in these facilities. The authors then examined relationships between ASC market share and rates of each procedure. Age-adjusted rates of ambulatory surgery ranged from 190.5 cases per 1000 to 320.8 cases per 1000 in HSAs with low and high ASC market shares, respectively (P < .01). For all 4 procedures, adjusted rates of procedures were significantly higher in HSAs with the highest ASC market share. The greatest difference, both in relative and absolute terms, was observed for patients undergoing cystoscopy. In areas of high ASC market share, the age-adjusted rate of cystoscopy was nearly 3-fold higher than in areas with low ASC market share (34.5 vs 11.9 per 1000 population; P < .01). The presence of an ASC is associated with higher utilization of common outpatient procedures in the elderly. Whether ASCs are meeting unmet clinical demand or spurring overutilization is not clear.

Risk Factors for new accidental falls in elderly patients at traumatology ambulatory center.

PubMed

Porto Gautério, Daiane; Zortea, Bruna; Costa Santos, Silvana Sidney; da Silva Tarouco, Bárbara; Lopes, Manoel José; João Fonseca, Cesar

2015-01-01

To identify the risks factors for new accidental falls in elderly patients attended in the Traumatology Ambulatory of a University hospital in Rio Grande do Sul, Brazil. Quantitative study of the type of multiple cases. Performed at the traumatology ambulatory, amongst fifteen elders that attended the inclusion criteria: age of sixty or more; patient at the traumatology ambulatory because of a fall motivated by accident, oriented and in conditions of answer an interview of data collectors. The data collection was made between April and June, 2013, with the Elderly Nursing Core Set scale (Lopes & Fonseca). The data analysis was made by a descriptive structure, which helped identify the existence of relation patterns among the cases. The risk factors for new accidental falls identified with larger incidence amongst the elders studied were: impaired balance (15/15), age above 65 (11/15), use of antihypertensive drugs (9/15), absence of non-slip material at home environment (7/15), in seven cases; rugs scattered at the floor of the house (6/15). The combination of intrinsic and extrinsic factors that include the environmental risks is considered a much more relevant cause to occur the new falls. The minimization of the home dangers, allied to the control of the elder intrinsic factors, may reduce the risks of causes. In that sense, is necessary that the nursing team make available more attention to the elderly assisted at the ambulatories, mainly those with sequelae due to fall accidents.

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

Home monitoring after ambulatory implanted primary cardiac implantable electronic devices: The home ambulance pilot study.

PubMed

Parahuleva, Mariana S; Soydan, Nedim; Divchev, Dimitar; Lüsebrink, Ulrich; Schieffer, Bernhard; Erdogan, Ali

2017-11-01

The Home Monitoring (HM) system of cardiac implantable electronic devices (CIEDs) permits early detection of arrhythmias or device system failures. The aim of this pilot study was to examine how the safety and efficacy of the HM system in patients after ambulatory implanted primary CIEDs compare to patients with a standard procedure and hospitalization. We hypothesized that HM and their modifications would be a useful extension of the present concepts for ambulatory implanted CIEDs. This retrospective analysis evaluates telemetric data obtained from 364 patients in an ambulatory single center over 6 years. Patients were assigned to an active group (n = 217), consisting of those who were discharged early on the day of implantation of the primary CIED, or to a control group (n = 147), consisting of those discharged and followed up with the HM system according to usual medical practices. The mean duration of hospitalization was 73.2% shorter in the active group than in the control group, corresponding to 20.5 ± 13 fewer hours (95% confidence interval [CI]: 6.3-29.5; P < 0.01) spent in the hospital (7.5 ± 1.5 vs 28 ± 4.5 h). This shorter mean hospital stay was attributable to a 78.8% shorter postoperative period in the active group. The proportion of patients with treatment-related adverse events was 11% (n = 23) in the active group and 17% (n = 25) in the control group (95% CI: 5.5-8.3; P = 0.061). This 6% absolute risk reduction (95% CI: 3.3-9.1; P = 0.789) confirmed the noninferiority of the ambulatory implanted CIED when compared with standard management of these patients. Early discharge with the HM system after ambulatory CIED implantation was safe and not inferior to the classic medical procedure. Thus, together with lower costs, HM and its modifications would be a useful extension of the present concepts for ambulatory implanted CIEDs. © 2017 Wiley Periodicals, Inc.

The Impact of Electronic Health Records on Ambulatory Costs Among Medicaid Beneficiaries

PubMed Central

Adler-Milstein, Julia; Salzberg, Claudia; Franz, Calvin; Orav, E. John; Bates, David Westfall

2013-01-01

Background Broad adoption of electronic health records (EHRs) is a potential strategy for curbing healthcare cost growth, which is particularly vital for Medicaid. Despite limited evidence for EHR-related cost savings, the 2009 HITECH Act included incentives for providers to become meaningful users of EHRs. We evaluated a large Massachusetts EHR pilot to obtain early insight into the potential for the national strategy to reduce short-run healthcare costs in the Medicaid population. Methods We calculated monthly ambulatory cost and visit measures from Medicaid claims data for beneficiaries receiving the majority of their care in the three Massachusetts eHealth Collaborative (MAeHC) pilot communities or in six matched control communities. Using a difference-in-differences of slope analysis, we assessed whether cost and visit trajectories differed in the pre-implementation period compared to the post-implementation period for intervention and control community members. Results We found evidence that EHR adoption impacted ambulatory medical cost in two of the three communities, but the effects were in opposite directions. Ambulatory medical costs increased more slowly in one intervention compared to its control communities in the pre-to-post period (difference-in-differences=-1.98%, p<0.001; PMPM savings of $41.60). In contrast, for a second pilot community, ambulatory medical cost increased more slowly in the control communities (difference-in-differences=2.56%, p=0.005; PMPM increase of $43.34). Conclusions As a stand-alone approach, adoption of commercially-available EHRs in community practices did not consistently impact Medicaid costs in the short-run. This suggests that future meaningful use criteria may need to specifically target cost savings and coordinate with payment reform efforts. PMID:24753965

[The role of ambulatory electroencephalogram monitoring: experience and results in 264 records].

PubMed

González de la Aleja, J; Saiz Díaz, R A; Martín García, H; Juntas, R; Pérez-Martínez, D; de la Peña, P

2008-11-01

Ambulatory electroencephalogram (EEG) monitoring allows for long-term, mobile electroencephalographic recordings of patients. This study aims to describe and analyze the results obtained with ambulatory EEG in our clinical practice. We have analyzed the results of 264 ambulatory EEG records, grouped according to the reason for the request: a) group 1: diagnostic evaluation of episodes of epileptic nature; b) group 2: diagnostic evaluation of paroxysmal episodes, and c) group 3: evaluation of the risk of relapse during anti-seizure treatment withdrawal in certain epileptic patients. a) Group 1 (n=137): normal results were found in 54 records (39.4%). There was generalized epileptic activity in 20 (14.6%) of them (5 with ictal activity) and focal epileptic activity was detected in 57 cases (42%) (8 with ictal activity). No EEG diagnosis could be reached in 6 (4%) recordings due to the presence of artefacts; b) group 2 (n=99): in 47 records (47.5 %), there were no episodes and the Holter-EEG was normal. There was a clinically documented episode without anomalies during Holter-EEG registration in 14 cases (14.2%). In 29 records (29.3%), focal epileptic activity was recorded (ictal 4) and generalized epileptic activity (ictal in 1) was recorded in 4 patients (4%). No EEG diagnosis could be reached in 5 cases (5%), and c) group 3 (n=28): the study was normal in 15 cases (53.6%) and showed focal interictal epileptic activity in 8 (28.6 %) and generalized interictal epileptic activity in 5 of them (17.8%). We believe that the ambulatory EEG recordings in correctly selected cases can provide important additional information regarding global assessment of patients with epilepsy.

The demand for ambulatory mental health services from specialty providers.

PubMed Central

Horgan, C M

1986-01-01

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

Salivary cortisol in ambulatory assessment--some dos, some don'ts, and some open questions.

PubMed

Kudielka, Brigitte M; Gierens, Andrea; Hellhammer, Dirk H; Wüst, Stefan; Schlotz, Wolff

2012-05-01

The impact of stress on health and disease is an important research topic in psychosomatic medicine. Because research on hypothalamic-pituitary-adrenal (HPA) axis regulation under controlled laboratory studies lacks ecological validity, it needs to be complemented by a research program that includes momentary ambulatory assessment. The measurement of salivary cortisol offers the possibility to trace the free steroid hormone concentrations in ambulant settings. Therefore, in this article, we first discuss the role of salivary cortisol in ambulatory monitoring. We start with a brief description of HPA axis regulation, and we then consider cortisol assessments in other organic materials, followed by a presentation of common salivary markers of HPA axis regulation suitable for ambulatory assessment. We further provide an overview on assessment designs and sources of variability within and between subjects (intervening variables), acknowledge the issue of (non)compliance, and address statistical aspects. We further give an overview of associations with psychosocial and health-related variables relevant for ambulatory assessment. Finally, we deal with preanalytical aspects of laboratory salivary cortisol analysis. The relative simplicity of salivary cortisol assessment protocols may lead to an overoptimistic view of the robustness of this method. We thus discuss several important issues related to the collection and storage of saliva samples and present empirical data on the stability of salivary cortisol measurements over time.

An Analysis of Ambulatory Teaching Situations for Faculty Development.

ERIC Educational Resources Information Center

Simpson, Deborah E.; And Others

1990-01-01

A study identified variables perceived by clinical medical faculty (n=20) to influence the ease or difficulty of teaching in the ambulatory care setting. Characteristics affecting the teaching situation included teacher, student, and patient characteristics. Implications for faculty development on teaching in the clinical setting are discussed.…

Blood pressure variability of two ambulatory blood pressure monitors.

PubMed

Kallem, Radhakrishna R; Meyers, Kevin E C; Cucchiara, Andrew J; Sawinski, Deirdre L; Townsend, Raymond R

2014-04-01

There are no data on the evaluation of blood pressure (BP) variability comparing two ambulatory blood pressure monitoring monitors worn at the same time. Hence, this study was carried out to compare variability of BP in healthy untreated adults using two ambulatory BP monitors worn at the same time over an 8-h period. An Accutorr device was used to measure office BP in the dominant and nondominant arms of 24 participants.Simultaneous 8-h BP and heart rate data were measured in 24 untreated adult volunteers by Mobil-O-Graph (worn for an additional 16 h after removing the Spacelabs monitor) and Spacelabs with both random (N=12) and nonrandom (N=12) assignment of each device to the dominant arm. Average real variability (ARV), SD, coefficient of variation, and variation independent of mean were calculated for systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pulse pressure (PP). Whether the Mobil-O-Graph was applied to the dominant or the nondominant arm, the ARV of mean systolic (P=0.003 nonrandomized; P=0.010 randomized) and PP (P=0.009 nonrandomized; P=0.005 randomized) remained significantly higher than the Spacelabs device, whereas the ARV of the mean arterial pressure was not significantly different. The average BP readings and ARVs for systolic blood pressure and PP obtained by the Mobil-O-Graph were considerably higher for the daytime than the night-time. Given the emerging interest in the effect of BP variability on health outcomes, the accuracy of its measurement is important. Our study raises concerns about the accuracy of pooling international ambulatory blood pressure monitoring variability data using different devices.

Devices for Ambulatory Monitoring of Sleep-Associated Disorders in Children with Neurological Diseases.

PubMed

Ulate-Campos, Adriana; Tsuboyama, Melissa; Loddenkemper, Tobias

2017-12-25

Good sleep quality is essential for a child's wellbeing. Early sleep problems have been linked to the later development of emotional and behavioral disorders and can negatively impact the quality of life of the child and his or her family. Sleep-associated conditions are frequent in the pediatric population, and even more so in children with neurological problems. Monitoring devices can help to better characterize sleep efficiency and sleep quality. They can also be helpful to better characterize paroxysmal nocturnal events and differentiate between nocturnal seizures, parasomnias, and obstructive sleep apnea, each of which has a different management. Overnight ambulatory detection devices allow for a tolerable, low cost, objective assessment of sleep quality in the patient's natural environment. They can also be used as a notification system to allow for rapid recognition and prompt intervention of events like seizures. Optimal monitoring devices will be patient- and diagnosis-specific, but may include a combination of modalities such as ambulatory electroencephalograms, actigraphy, and pulse oximetry. We will summarize the current literature on ambulatory sleep devices for detecting sleep disorders in children with neurological diseases.

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

PubMed

Tourigny, Jocelyne; Chartrand, Julie; Massicotte, Julie

2008-01-01

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

Challenges to Safe Injection Practices in Ambulatory Care.

PubMed

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

2017-05-01

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

Ambulatory obstetrical care: strategies to reduce telephone liability.

PubMed

Phelan, J P

1998-09-01

The telephone will become the centerpiece of ambulatory care services. As such, a pertinent aspect of office procedures will necessarily include a protocol to manage and document telephone calls. Encourage your office staff to use good telephone manners, as listed in Table 5. The net result should be a reduction in telephone liability risks and an enhanced reputation for your office.

Nationwide use and outcomes of ambulatory surgery in morbidly obese patients in the United States.

PubMed

Rosero, Eric B; Joshi, Girish P

2014-05-01

To compare the overall characteristics and perioperative outcomes in morbidly obese and nonobese patients undergoing ambulatory surgery in the United States. Retrospective, propensity-matched cohort study. Academic medical center. The association between duration of surgical procedures, postoperative complications, and unplanned hospital admission was assessed in a propensity-matched cohort of morbidly obese and nonobese patients derived from the 2006 National Survey of Ambulatory Surgery. Only 0.32% of the ambulatory procedures were performed on morbidly obese patients. The morbidly obese were significantly younger but had a higher burden of comorbidities, were more likely to undergo the procedure in hospital-based outpatient departments (HOPD; 80.1% vs 56.5%; P = 0.004), and had significantly shorter procedures than the nonobese (median [interquartile range], 28 [21-38] vs 42 [22-65] min; P < 0.0001). The incidences of postoperative hypertension, hypotension, hypoxia, cancellation of surgery, and unplanned hospital admissions did not differ significantly between groups. Similarly, adjusted rates of delayed discharge were similar in morbidly obese and nonobese patients (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.18 - 1.15; P = 0.09). In contrast, morbid obesity was associated with decreased odds of postoperative nausea and vomiting (OR, 0.27; CI, 0.09 - 0.84; P = 0.01). In 2006 in the U.S., the prevalence of ambulatory surgery in the morbidly obese was low, with most of the procedures being performed in the HOPD facilities, suggesting a conservative patient selection. The incidence of adverse postoperative outcomes and delayed discharge, as well as unplanned hospital admission after ambulatory surgery in the morbidly obese, was similar to that reported in the nonobese. Copyright © 2014 Elsevier Inc. All rights reserved.

Determining suitability for home versus community-based ambulatory therapy services for adults with arthritis.

PubMed

Rothman, L M; Badley, E M

1996-02-01

A survey of clients seen by a community-based arthritis therapy service was conducted to investigate how characteristics of clients might provide information to assist in the development of guidelines for services delivered in the home versus in a community-based ambulatory setting. Clients completed a self-administered questionnaire, which included the Health Assessment Questionnaire, and a mobility handicap measure. Two indicator variables selected as criteria for suitability for ambulatory therapy were the therapists' rating of client suitability and the clients' report of going out more than once weekly. Based on these indicator variables, 60-76% of clients currently receiving home therapy by this service could potentially receive services in a community-based ambulatory setting. The results demonstrate the usefulness of considering client characteristics when deciding whether clients need to be seen at home. This study emphasizes the need to determine the most efficient and effective methods of providing services to people in the community with chronic conditions.

Support Vector Machines to improve physiologic hot flash measures: application to the ambulatory setting.

PubMed

Thurston, Rebecca C; Hernandez, Javier; Del Rio, Jose M; De La Torre, Fernando

2011-07-01

Most midlife women have hot flashes. The conventional criterion (≥2 μmho rise/30 s) for classifying hot flashes physiologically has shown poor performance. We improved this performance in the laboratory with Support Vector Machines (SVMs), a pattern classification method. We aimed to compare conventional to SVM methods to classify hot flashes in the ambulatory setting. Thirty-one women with hot flashes underwent 24 h of ambulatory sternal skin conductance monitoring. Hot flashes were quantified with conventional (≥2 μmho/30 s) and SVM methods. Conventional methods had low sensitivity (sensitivity=.57, specificity=.98, positive predictive value (PPV)=.91, negative predictive value (NPV)=.90, F1=.60), with performance lower with higher body mass index (BMI). SVMs improved this performance (sensitivity=.87, specificity=.97, PPV=.90, NPV=.96, F1=.88) and reduced BMI variation. SVMs can improve ambulatory physiologic hot flash measures. Copyright © 2010 Society for Psychophysiological Research.

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

PubMed

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

2016-10-01

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. 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). 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. Among homeless-experienced Veterans, permanent supported housing may reduce disparities in the treatment of diagnoses commonly seen in ambulatory care. © The Author(s) 2016.

A Marketing Analysis to Determine the Consumer Demand for Ambulatory Surgery at Darnall Army Community Hospital, Fort Hood, Texas

DTIC Science & Technology

1982-08-01

8 Marketing Research ...... ................................9 The Marketing Audit...9 A Marketing Research Model .... ..........................10 An Ambulatory Marketing Model. .... ......................12 Stage 1. Internal...14 Stage 4. Modifications of Internal Projecttons. .. ......14 Marketing Research on Ambulatory Surgical Centers .. ........15 Research

Administrative Data Algorithms Can Describe Ambulatory Physician Utilization

PubMed Central

Shah, Baiju R; Hux, Janet E; Laupacis, Andreas; Zinman, Bernard; Cauch-Dudek, Karen; Booth, Gillian L

2007-01-01

Objective To validate algorithms using administrative data that characterize ambulatory physician care for patients with a chronic disease. Data Sources Seven-hundred and eighty-one people with diabetes were recruited mostly from community pharmacies to complete a written questionnaire about their physician utilization in 2002. These data were linked with administrative databases detailing health service utilization. Study Design An administrative data algorithm was defined that identified whether or not patients received specialist care, and it was tested for agreement with self-report. Other algorithms, which assigned each patient to a primary care and specialist physician, were tested for concordance with self-reported regular providers of care. Principal Findings The algorithm to identify whether participants received specialist care had 80.4 percent agreement with questionnaire responses (κ = 0.59). Compared with self-report, administrative data had a sensitivity of 68.9 percent and specificity 88.3 percent for identifying specialist care. The best administrative data algorithm to assign each participant's regular primary care and specialist providers was concordant with self-report in 82.6 and 78.2 percent of cases, respectively. Conclusions Administrative data algorithms can accurately match self-reported ambulatory physician utilization. PMID:17610448

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

PubMed

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

2011-06-01

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

Preoperative intravenous parecoxib reduces length of stay on ambulatory laparoscopic cholecystectomy.

PubMed

Shuying, Li; Xiao, Wang; Peng, Liang; Tao, Zhu; Ziying, Lu; Liang, Zhao

2014-01-01

The complexity of pain after laparoscopic cholecystectomy (LC) needs multi-module analgesia. Opioids are widely used for perioperative pain but associated with numerous adverse effects. We investigated the effect of parecoxib administrated preoperatively and postoperatively for analgesia after ambulatory laparoscopic cholecystectomy. 120 patients scheduled for ambulatory LC with general anesthesia were randomly assigned to three groups: group A received 40 mg parecoxib injection 30-45 min before anesthesia induction and 4 ml saline injection when gallbladder was removed; group B received 4 ml saline injection 30-45 min before anesthesia induction and 40 mg parecoxib injection when gallbladder was removed; group C received 4 ml saline injection 30-45 min before anesthesia induction and the time when gallbladder was removed. We recorded the time achieve to modified Aldrete's score > 9 in the post-anesthesia care unit (PACU) and modified Post-Anesthetic Discharge Scoring System (PADSS) > 9 in ambulatory unit. The visual analog scale (VAS) was used to assess the degree of the postoperative pain in the first 24 h, and the numbers of patients who need additional analgesic and postoperative adverse effects were also recorded. Patients of group A had a shorter length of stay (LOS) in PACU compared to these of group B and group C (32.4 ± 7.2 min vs. 39.1 ± 10.4 min and 42.2 ± 7.6 min, P < 0.05). Patients of group A also had a shorter discharge time compared to these of group B and group C (148.4 ± 39.3 min vs. 187.9 ± 47.7 min and 223.4 ± 52.5 min, P < 0.05). Moreover, patients of group A experienced reduced pain intensity, less postoperative side effect, and less additional analgesic requirement. Preoperative administration of parecoxib for postoperative analgesia provided significant effect on reducing PACU length of stay (LOS) and discharge time, and improving patient outcome after ambulatory LC. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd

Comparison of laboratory and ambulatory measures of central blood pressure and pulse wave reflection: hitting the target or missing the mark?

PubMed

Burns, Matthew J; Seed, Jeremy D; Incognito, Anthony V; Doherty, Connor J; Notay, Karambir; Millar, Philip J

2018-04-01

Prior studies demonstrating clinical significance of noninvasive estimates of central blood pressure (BP) and pulse wave reflection have relied primarily on discrete resting measures. The aim of this study was to compare central BP and pulse wave reflection measures sampled during a single resting laboratory visit against those obtained under ambulatory conditions. The secondary aim was to investigate the reproducibility of ambulatory central BP and pulse wave reflection measurements. Forty healthy participants (21 males; 24 ± 3 years) completed three measurements of brachial artery pulse wave analysis (Oscar 2 with SphygmoCor Inside) in the laboratory followed by 24 hours of ambulatory monitoring. Seventeen participants repeated the 24-hour ambulatory monitoring visit after at least 1 week. Ambulatory measures were divided into daytime (9 AM-9 PM), nighttime (1 AM-6 AM), and 24-hour periods. Compared with laboratory measurements, central systolic BP, augmentation pressure, and augmentation index (with and without heart rate normalization) were higher (all P < .01) during daytime and 24-hour periods but lower during the nighttime period (all P < .001). The drop in nighttime brachial systolic BP was larger than central systolic pressure (Δ -20 ± 6 vs. -15 ± 6 mm Hg; P < .0001). Repeat ambulatory measurements of central BP and pulse wave reflection displayed good-to-excellent intraclass correlation coefficients (r = 0.58-0.86; all P < .01), although measures of pulse wave reflection had higher coefficients of variation (14%-41%). The results highlight absolute differences in central BP and pulse wave reflection between discrete laboratory and ambulatory conditions. The use of ambulatory measures of central BP and pulse wave reflection warrant further investigation for clinical prognostic value. Copyright © 2018 American Heart Association. Published by Elsevier Inc. All rights reserved.

Impact of renal denervation on 24-hour ambulatory blood pressure: results from SYMPLICITY HTN-3.

PubMed

Bakris, George L; Townsend, Raymond R; Liu, Minglei; Cohen, Sidney A; D'Agostino, Ralph; Flack, John M; Kandzari, David E; Katzen, Barry T; Leon, Martin B; Mauri, Laura; Negoita, Manuela; O'Neill, William W; Oparil, Suzanne; Rocha-Singh, Krishna; Bhatt, Deepak L

2014-09-16

Prior studies of catheter-based renal artery denervation have not systematically performed ambulatory blood pressure monitoring (ABPM) to assess the efficacy of the procedure. SYMPLICITY HTN-3 (Renal Denervation in Patients With Uncontrolled Hypertension) was a prospective, blinded, randomized, sham-controlled trial. The current analysis details the effect of renal denervation or a sham procedure on ABPM measurements 6 months post-randomization. Patients with resistant hypertension were randomized 2:1 to renal denervation or sham control. Patients were on a stable antihypertensive regimen including maximally tolerated doses of at least 3 drugs including a diuretic before randomization. The powered secondary efficacy endpoint was a change in mean 24-h ambulatory systolic blood pressure (SBP). Nondipper to dipper (nighttime blood pressure [BP] 10% to 20% lower than daytime BP) conversion was calculated at 6 months. The 24-h ambulatory SBP changed -6.8 ± 15.1 mm Hg in the denervation group and -4.8 ± 17.3 mm Hg in the sham group: difference of -2.0 mm Hg (95% confidence interval [CI]: -5.0 to 1.1; p = 0.98 with a 2 mm Hg superiority margin). The daytime ambulatory SBP change difference between groups was -1.1 (95% CI: -4.3 to 2.2; p = 0.52). The nocturnal ambulatory SBP change difference between groups was -3.3 (95 CI: -6.7 to 0.1; p = 0.06). The percent of nondippers converted to dippers was 21.2% in the denervation group and 15.0% in the sham group (95% CI: -3.8% to 16.2%; p = 0.30). Change in 24-h heart rate was -1.4 ± 7.4 in the denervation group and -1.3 ± 7.3 in the sham group; (95% CI: -1.5 to 1.4; p = 0.94). This trial did not demonstrate a benefit of renal artery denervation on reduction in ambulatory BP in either the 24-h or day and night periods compared with sham (Renal Denervation in Patients With Uncontrolled Hypertension [SYMPLICITY HTN-3]; NCT01418261). Copyright © 2014 American College of Cardiology Foundation. Published by

The Evolution of Ambulatory Medical Record Systems in the U.S

PubMed Central

Kuhn, Ingeborg M.; Wiederhold, Gio

1981-01-01

This paper is an overview of the developments in Automated Ambulatory Medical Record Systems (AAMRS) from 1975 to the present. A summary of findings from a 1975 state-of-the-art review is presented with the current findings of a follow-up study of the AAMRS. The studies revealed that effective automated medical record systems have been developed for ambulatory care settings and that they are now in the process of being transfered to other sites or users, either privately or as a commercial product. Since 1975 there have been no significant advances in system design. However, progress has been substantial in terms of achieving production goals. Even though a variety of system are commercially available, there is a continuing need for research and development to improve the effectiveness of the systems in use today.

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.

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

Ambulatory Aortic Stiffness Is Associated With Narrow Retinal Arteriolar Caliber in Hypertensives: The SAFAR Study.

PubMed

Aissopou, Evaggelia K; Argyris, Antoniοs A; Nasothimiou, Efthimia G; Konstantonis, George D; Tampakis, Kostas; Tentolouris, Nikolaos; Papathanassiou, Miltiadis; Theodossiadis, Panagiotis G; Papaioannou, Theodoros G; Stehouwer, Coen D A; Sfikakis, Petros P; Protogerou, Athanassios D

2016-05-01

Arterial stiffness measured under static conditions reclassifies significantly cardiovascular (CV) risk and associates with narrower retinal arterioles. However, arterial stiffness exhibits circadian variation, thus single static stiffness recordings do not correspond to the "usual" 24 hr, awake, and asleep average arterial stiffness. We aimed to test the hypothesis that ambulatory 24 hr, awake, and asleep aortic (a) pulse wave velocity (PWV) associate with retinal vessel calibers, independently of confounders and of static arterial stiffness, in hypertensive individuals free from diabetes and CV disease. Digital retinal images were obtained (181 individuals, age: 53.9±10.7 years, 55.2% men) and retinal vessel calibers were measured with validated software to determine central retinal arteriolar and venular equivalents (CRAE and CRVE, respectively); ambulatory (24 hr, awake, asleep) and static office aPWV were estimated by Mobil-O-Graph; and static office carotid to femoral (cf) PWV by SphygmoCor. Regression analysis performed in 320 gradable retinal images showed that, after adjustment for confounders: (i) ambulatory aPWV was significantly associated with narrower retinal arterioles but not with venules; (ii) asleep aPWV had stronger associations with CRAE than awake aPWV; (iii) both ambulatory aPWV and cfPWV were associated mutually independently with narrower retinal arterioles; aPWV introduction in the model of cfPWV, improved model's R2 (P = 0.012). Similar discriminatory ability of 24 hr aPWV and of cfPWV to detect the presence of retinal arteriolar narrowing was found. Ambulatory aPWV, estimated by an operator-independent method, provides additional information to cfPWV regarding the associations of arterial stiffness with the retinal vessel calibers. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Intelligent artifact classification for ambulatory physiological signals.

PubMed

Sweeney, Kevin T; Leamy, Darren J; Ward, Tomas E; McLoone, Sean

2010-01-01

Connected health represents an increasingly important model for health-care delivery. The concept is heavily reliant on technology and in particular remote physiological monitoring. One of the principal challenges is the maintenance of high quality data streams which must be collected with minimally intrusive, inexpensive sensor systems operating in difficult conditions. Ambulatory monitoring represents one of the most challenging signal acquisition challenges of all in that data is collected as the patient engages in normal activities of everyday living. Data thus collected suffers from considerable corruption as a result of artifact, much of it induced by motion and this has a bearing on its utility for diagnostic purposes. We propose a model for ambulatory signal recording in which the data collected is accompanied by labeling indicating the quality of the collected signal. As motion is such an important source of artifact we demonstrate the concept in this case with a quality of signal measure derived from motion sensing technology viz. accelerometers. We further demonstrate how different types of artifact might be tagged to inform artifact reduction signal processing elements during subsequent signal analysis. This is demonstrated through the use of multiple accelerometers which allow the algorithm to distinguish between disturbance of the sensor relative to the underlying tissue and movement of this tissue. A brain monitoring experiment utilizing EEG and fNIRS is used to illustrate the concept.

Ambulatory surgery: is the liability risk lower?

PubMed

Metzner, Julia; Kent, Christopher D

2012-12-01

To summarize the currently available data on malpractice claims related to ambulatory anesthesia and provide an insight into the emerging patterns of anesthesia liability in this practice setting. At present, studies are mixed about how the continued growth of outpatient surgery will impact liability for anesthesiologists. Data derived from the ASA Closed Claims Project suggests that malpractice claims for major damaging events are less common in the outpatient settings than in inpatient settings. Correspondingly, the payment amounts for outpatient claims are significantly lower than those for inpatients. Nevertheless, nondisabling adverse events are common and involve respiratory, cardiac, equipment-related, and drug errors. In addition, the vast majority of injuries in outpatient claims was the result of substandard care and judged preventable by better monitoring. Although major incidents leading to malpractice suits are less, new liability exposure may be on the horizon, due to the changing landscape of ambulatory practice that permits care for sicker patients who require more complex surgeries. The areas of potential concern include postoperative discharge criteria, care for the obstructive sleep apnea patient, and the choice of anesthetic techniques such as neuraxial blocks and monitored anesthesia care. With steady increase in outpatient surgery, anesthesiologists are confronted with new areas of liability. More data are needed to identify these risks and reduce exposure to malpractice claims.

Analysis of failed discharge after ambulatory surgery: unanticipated admission.

PubMed

Van Caelenberg, Els; De Regge, Melissa; Eeckloo, Kristof; Coppens, Marc

2018-05-30

Advantages of ambulatory surgery are lost when patients need an unplanned admission. This retrospective cohort study investigated reasons for failed discharge and unanticipated admission of adult patients after day surgery. Ambulatory patients (n = 145) requiring unanticipated admission were compared to patients (n = 4980) not requiring admission and timely discharged from a total of 5156 ambulatory surgical procedures. Demographic data, organisational data, reason for admission, type of anesthesia, surgical discipline, length of procedure, ASA classification, surgical completion time and severity of illness score were collected from both groups. Reason for admission was classified according to four subtypes. Logistic regression analysis was used. Incidence of unanticipated admission following day care surgery was 2.89%. The reasons for admission were mainly organisational issues (45.52%), time of completion surgery in the afternoon between 12 pm and 3 pm (OR 1.73; 95% CI 1.05-2.86) and surgery that ends after 3 pm (OR 6.52; 95% CI 4.11-10.34). Surgical factors associated with unanticipated admission (38.62%) were length of surgery of one to three hours (OR 2.05; 95% CI 1.27-3.29), length of surgery more than three hours (OR 8.31; 95% CI 3.56-19.40). Additionally, anaesthetic (10.34%) and medical (5.52%) reasons were found, e.g. ASA class II (OR 1.61; 95% CI 1.06-2.44), ASA class III (OR 2.19; 95% CI 1.10-4.34); moderate severity of illness score (OR 1.72; 95% CI 1.03-2.88) and major of severity of illness score (OR 7.85; 95% CI 2.31-26.62). Unanticipated admissions following day surgery occur mainly due to social/organisational and surgical reasons. However, medical and anaesthetic reasons also explain 15.86% of the unanticipated admissions.

Social support and ambulatory blood pressure in older people.

PubMed

Sanchez-Martínez, Mercedes; López-García, Esther; Guallar-Castillón, Pilar; Cruz, Juan J; Orozco, Edilberto; García-Esquinas, Esther; Rodríguez-Artalejo, Fernando; Banegas, José R

2016-10-01

Social support has been associated with greater nocturnal decline (dipping) in blood pressure (BP) in younger and middle-aged individuals. However, it is uncertain if aggregated measures of social support are related to ambulatory SBP in older adults, where high SBP is frequent and clinically challenging. We studied 1047 community-living individuals aged at least 60 years in Spain. Twenty-four-hour ambulatory BP was determined under standardized conditions. Social support was assessed with a seven-item questionnaire on marital status, cohabitation, frequency of contact with relatives, or with friends and neighbors, emotional support, instrumental support, and outdoor companionship. A social support score was built by summing the values of the items that were significantly associated with SBP variables, such that the higher the score, the better the support. Participants' mean age was 71.7 years (50.8% men). Being married, cohabiting, and being accompanied when out of home were the support items significantly associated with SBP variables. After adjustment for sociodemographic (age, sex, education), behavioral (BMI, alcohol, tobacco, salt consumption, physical activity, Mediterranean diet score), and clinical variables [sleep quality, mental stress, comorbidity, BP medication, and ambulatory BP levels and heart rate (HR)], one additional point in the social support score built with the abovementioned three support variables, was associated with a decrease of 0.93 mmHg in night-time SBP (P = 0.039), totaling 2.8 mmHg decrease for a score of 3 vs. 0. The three-item social support score was also inversely associated with the night/day SBP ratio (β = -0.006, P = 0.010). In older adults, social support is independently associated with lower nocturnal SBP and greater SBP dipping. Further research is needed in prospective studies to confirm these results.

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.

The value of vendor-reported ambulatory EHR benefits data.

PubMed

Thompson, Douglas; Classen, David; Garrido, Terhilda; Bisordi, Joseph; Novogoratz, Scott; Zywiak, Walt

2007-04-01

Implementation of an electronic health record is expensive and labor-intensive. For this reason, providers often seek information about possible benefits to help them decide whether to implement an EHR. Our study found that a benefits database maintained by an ambulatory clinical systems vendor provided information that is useful, but that also has limitations.

Using cadence to study free-living ambulatory behaviour.

PubMed

Tudor-Locke, Catrine; Rowe, David A

2012-05-01

The health benefits of a physically active lifestyle across a person's lifespan have been established. If there is any single physical activity behaviour that we should measure well and promote effectively, it is ambulatory activity and, more specifically, walking. Since public health physical activity guidelines include statements related to intensity of activity, it follows that we need to measure and promote free-living patterns of ambulatory activity that are congruent with this intent. The purpose of this review article is to present and summarize the potential for using cadence (steps/minute) to represent such behavioural patterns of ambulatory activity in free-living. Cadence is one of the spatio-temporal parameters of gait or walking speed. It is typically assessed using short-distance walks in clinical research and practice, but free-living cadence can be captured with a number of commercially available accelerometers that possess time-stamping technology. This presents a unique opportunity to use the same metric to communicate both ambulatory performance (assessed under testing conditions) and behaviour (assessed in the real world). Ranges for normal walking cadence assessed under laboratory conditions are 96-138 steps/minute for women and 81-135 steps/minute for men across their lifespan. The correlation between mean cadence and intensity (assessed with indirect calorimetry and expressed as metabolic equivalents [METs]) based on five treadmill/overground walking studies, is r = 0.93 and 100 steps/minute is considered to be a reasonable heuristic value indicative of walking at least at absolutely-defined moderate intensity (i.e. minimally, 3 METs) in adults. The weighted mean cadence derived from eight studies that have observed pedestrian cadence under natural conditions was 115.2 steps/minute, demonstrating that achieving 100 steps/minute is realistic in specific settings that occur in real life. However, accelerometer data collected in a large

Acceptance of Ambulatory Laparoscopic Cholecystectomy in Central Switzerland.

PubMed

Widjaja, Sandra P; Fischer, Henning; Brunner, Alexander R; Honigmann, Philipp; Metzger, Jürg

2017-11-01

Currently, most patients undergoing laparoscopic cholecystectomy (LC) in Switzerland are inpatients for 2-3 days. Due to a lack of available hospital beds, we asked whether day-case surgery would be an option for patients in central Switzerland. The questions of acceptability of outpatient LC and factors contributing to the acceptability thus arose. Hundred patients suffering from symptomatic cholecystolithiasis, capable of communicating in German, and between 18 and 65 years old, were included. Patients received a pre-operative questionnaire on medical history and social situation when informed consent on surgery and participation in the study was obtained. Exclusion criteria were patients suffering from acute cholecystitis or any type of cancer; having a BMI >40 kg/m 2 ; needing conversion to open cholecystectomy or an intraoperative drainage; and non-German speakers. Surgery was performed laparoscopically. Both surgeon and patient filled in a postoperative questionnaire. The surgeon's questionnaire listed medical and technical information, and the patients' questionnaire listed medical information, satisfaction with the treatment and willingness to be released on the same day. These data from both questionnaires were grouped into social and medical factors and analysed on their influence upon willingness to accept an ambulatory procedure. No outpatient follow-up apart from checking for readmission to our hospital within 1 month after discharge was performed. Of the 100 participants, one-third was male. More than two-thirds were Swiss citizens. Only one participant was ineligible for rapid release evaluation due to need of a drainage. Among the social factors contributing to the acceptability of ambulatory care, we found nationality to be relevant; Swiss citizens preferred an inpatient procedure, whereas non-Swiss citizens were significantly more willing to return home on the same day. Household size, sex and age did not correlate with a preference for

Multisource Feedback in the Ambulatory Setting

PubMed Central

Warm, Eric J.; Schauer, Daniel; Revis, Brian; Boex, James R.

2010-01-01

Background The Accreditation Council for Graduate Medical Education has mandated multisource feedback (MSF) in the ambulatory setting for internal medicine residents. Few published reports demonstrate actual MSF results for a residency class, and fewer still include clinical quality measures and knowledge-based testing performance in the data set. Methods Residents participating in a year-long group practice experience called the “long-block” received MSF that included self, peer, staff, attending physician, and patient evaluations, as well as concomitant clinical quality data and knowledge-based testing scores. Residents were given a rank for each data point compared with peers in the class, and these data were reviewed with the chief resident and program director over the course of the long-block. Results Multisource feedback identified residents who performed well on most measures compared with their peers (10%), residents who performed poorly on most measures compared with their peers (10%), and residents who performed well on some measures and poorly on others (80%). Each high-, intermediate-, and low-performing resident had a least one aspect of the MSF that was significantly lower than the other, and this served as the basis of formative feedback during the long-block. Conclusion Use of multi-source feedback in the ambulatory setting can identify high-, intermediate-, and low-performing residents and suggest specific formative feedback for each. More research needs to be done on the effect of such feedback, as well as the relationships between each of the components in the MSF data set. PMID:21975632

Waiting times in the ambulatory sector--the case of chronically ill patients.

PubMed

Sundmacher, Leonie; Kopetsch, Thomas

2013-09-10

First, the influence of determinants on the waiting times of chronically ill patients in the ambulatory sector is investigated. The determinants are subdivided into four groups: (1) need, (2) socio-economic factors, (3) health system and (4) patient time pressures. Next, the influence of waiting times on the annual number of consultations is examined to assess whether the existing variation in waiting times influences the frequency of medical examinations. The waiting times of chronically ill patients are analysed since regular ambulatory care for this patient group could both improve treatment outcomes and lower costs. Individual data from the 2010 Representative Survey conducted by the National Association of Statutory Health Insurance Physicians (KBV) together with regional data from the Federal Office of Construction and Regional Planning. This is a retrospective observational study. The dependent variables are waiting times in the ambulatory sector and the number of consultations of General Practitioners (GPs) and specialist physicians in the year 2010. The explanatory variables of interest are 'need' and 'health system' in the first model and 'length of waiting times' in the second. Negative binomial models with random effects are used to estimate the incidence rate ratios of increased waiting times and number of consultations. Subsequently, the models are stratified by urban and rural areas. In the pooled regression the factor 'privately insured' shortens the waiting time for treatment by a specialist by approximately 28% (about 3 days) in comparison with members of the statutory health insurance system. The category of insurance has no influence on the number of consultations of GPs. In addition, the regression results stratified by urban and rural areas show that in urban areas the factor 'privately insured' reduces the waiting time for specialists by approximately 35% (about 3.3 days) while in rural areas there is no evidence of statistical influence. In

Skeletal muscle mass and exercise performance in stable ambulatory patients with heart failure.

PubMed

Lang, C C; Chomsky, D B; Rayos, G; Yeoh, T K; Wilson, J R

1997-01-01

The purpose of this study was to determine whether skeletal muscle atrophy limits the maximal exercise capacity of stable ambulatory patients with heart failure. Body composition and maximal exercise capacity were measured in 100 stable ambulatory patients with heart failure. Body composition was assessed by using dual-energy X-ray absorption. Peak exercise oxygen consumption (VO2peak) and the anaerobic threshold were measured by using a Naughton treadmill protocol and a Medical Graphics CardioO2 System. VO2peak averaged 13.4 +/- 3.3 ml.min-1.kg-1 or 43 +/- 12% of normal. Lean body mass averaged 52.9 +/- 10.5 kg and leg lean mass 16.5 +/- 3.6 kg. Leg lean mass correlated linearly with VO2peak (r = 0.68, P < 0.01), suggesting that exercise performance is influences by skeletal muscle mass. However, lean body mass was comparable to levels noted in 1,584 normal control subjects, suggesting no decrease in muscle mass. Leg muscle mass was comparable to levels noted in 34 normal control subjects, further supporting this conclusion. These findings suggest that exercise intolerance in stable ambulatory patients with heart failure is not due to skeletal muscle atrophy.

Comparison of valsartan and amlodipine on ambulatory blood pressure variability in hypertensive patients.

PubMed

Eguchi, Kazuo; Imaizumi, Yuki; Kaihara, Toshiki; Hoshide, Satoshi; Kario, Kazuomi

We tested the hypothesis that calcium channel blockers (CCBs: amlodipine group, n = 38)) are superior to angiotensin receptor blockers (ARBs: valsartan group, n = 38) against ambulatory blood pressure variability (BPV) in untreated Japanese hypertensive patients. Both drugs significantly reduced ambulatory systolic and diastolic BP values. With regard to BPV, standard deviation (SD) in SBP did not change with the administration of either drug, but the ARB significantly increased SD in awake DBP (12 ± 4-14 ± 4 mmHg). The ARB also significantly increased the coefficients of variation (CVs)in awake and 24-h SBP/DBP (all P < 0.05), but amlodipine did not change the CV. CCB significantly reduced the maximum values of awake SBP (193 ± 24-182 ± 27 mmHg, P = 0.02), sleep SBP (156 ± 18-139 ± 14 mmHg, P < 0 .001), and awake and sleep DBP (P < 0.01 in both cases), but the ARB did not change the maximum BP values. In conclusion, a once-daily morning dose of CCB amlodipine was more effective at controlling ambulatory BPV than ARB valsartan, especially in reducing maximum BP levels.

Successful Semi-Ambulatory Veno-Arterial Extracorporeal Membrane Oxygenation Bridge to Heart-Lung Transplantation in a Very Small Child.

PubMed

Wong, J Y W; Buchholz, H; Ryerson, L; Conradi, A; Adatia, I; Dyck, J; Rebeyka, I; Lien, D; Mullen, J

2015-08-01

Lung transplantation (LTx) may be denied for children on extracorporeal membrane oxygenation (ECMO) due to high risk of cerebral hemorrhage. Rarely has successful LTx been reported in children over 10 years of age receiving awake or ambulatory veno-venous ECMO. LTx following support with ambulatory veno-arterial ECMO (VA ECMO) in children has never been reported to our knowledge. We present the case of a 4-year-old, 12-kg child with heritable pulmonary artery hypertension and refractory right ventricular failure. She was successfully bridged to heart-lung transplantation (HLTx) using ambulatory VA ECMO. Initial resuscitation with standard VA ECMO was converted to an ambulatory circuit using Berlin heart cannulae. She was extubated and ambulating around her bed while on VA ECMO for 40 days. She received an HLTx from an oversized marginal lung donor. Despite a cardiac arrest and Grade 3 primary graft dysfunction, she made a full recovery without neurological deficits. She achieved 104% force expiratory volume in 1 s 33 months post-HLTx. Ambulatory VA ECMO may be a useful strategy to bridge very young children to LTx or HLTx. Patient tailored ECMO cannulation, minimization of hemorrhage, and thrombosis risks while on ECMO contributed to a successful HLTx in our patient. © Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.

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

PubMed

Epplen, Kelly T

2014-08-15

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

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

PubMed

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

2018-03-01

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

Developing from within: ensuring the ambulatory emergency care workforce is fit for purpose.

PubMed

Thurgate, Claire; Holmes, Sue

2015-11-01

Emergency healthcare provision is changing, and services need to respond to evolving health economies while providing safe, effective, patient-centred care. Ambulatory care is developing to meet these needs, but workforce planners need to ensure that staff are fit for purpose. To address this, one trust, in partnership with a local university, designed a bespoke in-house, work-based learning package on ambulatory care, which was delivered to registered nurses by practice experts. This article describes the project and discusses the evaluation, which highlighted the benefits of this way of learning for the nurses, the trust and the university, and identified some areas that require development.

The cost of medical education in an ambulatory neurology clinic.

PubMed Central

Abramovitch, Anna; Newman, William; Padaliya, Bimal; Gill, Chandler; Charles, P. David

2005-01-01

Decreased revenue from clinical services has required academic hospitals and physicians to improve productivity. Medical student education may be a significant hindrance to increased productivity and income. This study quantifies the amount of time spent by faculty members teaching medical students in an ambulatory neurology clinic as well as the amount of time students occupied rooms when seeing patients on their own. Over a three-week period in an ambulatory neurology clinic, an observer noted these quantities of time, and the opportunity costs of both amounts of time were determined. Attending physicians spent an average of 19.6 minutes per medical student per half-day teaching, which translates to an average cost of $20.78 per half-day clinic. Students spent an average of 49.9 minutes per half-day seeing patients in the absence of an attending physician, an opportunity cost to the clinic of $142.50 per student per half-day. PMID:16296220

Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience.

PubMed

Lalezari, Sepehr; Musielak, Matthew C; Broun, Lisa A; Curry, Trace W

2018-06-01

We present our experience with same-day discharge (without an overnight stay) after laparoscopic sleeve gastrectomy (SG) in 821 consecutive patients from 2011 to 2015. This is the largest series published to date of patients undergoing ambulatory surgery for such a procedure. To review our outcomes from ambulatory SG over 52 months to determine if SG can be safely performed in the ambulatory setting. Ambulatory surgery center. Retrospective review of all consecutive patients undergoing ambulatory SG from January 2011 to April 2015. All patients were discharged home the same day after surgery without an overnight stay at the hospital. Incidence of complications and admission to the hospital after discharge was reviewed up to 30 days from surgery. From January 2011 to April 2015, 821 consecutive patients underwent SG. Nineteen 30-day complications occurred in the series, 17 of them requiring admission to the hospital. Of the 19 cases, gastric leaks accounted for 7, intr-aabdominal abscess for 4, and dehydration/nausea/vomiting for 4; 4 were due to other causes. Complication and readmission rates at 30 days were 2.3% and 2.1%, respectively. Follow-up at 30 days was 98.4%. With stringent patient selection and utilization of enhanced recovery pathways, our study indicates that SG may be suitable for the outpatient setting. Experience and comfort with bariatric surgery is essential on the part of the operating surgeon to ensure good outcomes. Our low overall readmission and complication rate portends to the feasibility of laparoscopic SG as a safe outpatient procedure. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Evaluating ambulatory care training in Firoozgar hospital based on Iranian national standards of undergraduate medical education

PubMed Central

Sabzghabaei, Foroogh; Salajeghe, Mahla; Soltani Arabshahi, Seyed Kamran

2017-01-01

Background: In this study, ambulatory care training in Firoozgar hospital was evaluated based on Iranian national standards of undergraduate medical education related to ambulatory education using Baldrige Excellence Model. Moreover, some suggestions were offered to promote education quality in the current condition of ambulatory education in Firoozgar hospital and national standards using the gap analysis method. Methods: This descriptive analytic study was a kind of evaluation research performed using the standard check lists published by the office of undergraduate medical education council. Data were collected through surveying documents, interviewing, and observing the processes based on the Baldrige Excellence Model. After confirming the validity and reliability of the check lists, we evaluated the establishment level of the national standards of undergraduate medical education in the clinics of this hospital in the 4 following domains: educational program, evaluation, training and research resources, and faculty members. Data were analyzed according to the national standards of undergraduate medical education related to ambulatory education and the Baldrige table for scoring. Finally, the quality level of the current condition was determined as very appropriate, appropriate, medium, weak, and very weak. Results: In domains of educational program 62%, in evaluation 48%, in training and research resources 46%, in faculty members 68%, and in overall ratio, 56% of the standards were appropriate. Conclusion: The most successful domains were educational program and faculty members, but evaluation and training and research resources domains had a medium performance. Some domains and indicators were determined as weak and their quality needed to be improved, so it is suggested to provide the necessary facilities and improvements by attending to the quality level of the national standards of ambulatory education PMID:29951400

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.

Ambulatory hysteroscopy and its role in the management of abnormal uterine bleeding.

PubMed

Cooper, Natalie A M; Robinson, Lynne L L; Clark, T Justin

2015-10-01

Hysteroscopy is now an ambulatory procedure, having moved from a conventional day-case operating theatre environment to the outpatient clinic setting. Outpatient hysteroscopy can be used as a diagnostic test and as a therapeutic modality for women presenting with abnormal uterine bleeding. In many cases women can be diagnosed and treated efficiently during a single hospital appointment. This article reviews the development of ambulatory hysteroscopy and how it should optimally be performed and implemented. The contemporary role of this technology for investigating and treating women with abnormal uterine bleeding is then discussed. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Ear Acupuncture for Post-Operative Pain Associated with Ambulatory Arthroscopic Knee Surgery: A Randomized Controlled Trial

DTIC Science & Technology

2014-01-14

E7(/(3+21(180%(5 ,QFOXGHDUHDFRGH 14 Jan 2014 Final Report Ear acupuncture for post-operative pain associated with ambulatory arthroscopic...DISTRIBUTION A. Approved for public release: distribution unlimited. The purpose of this study is to compare ear acupuncture plus standard therapy versus...3298 Ear Acupuncture for Post-operative Pa111 Assoc1ated With Ambulatory Arthroscopic Knee Surgery A Randomized Controlled Trial ’• V ’’ ’-’ I

Development of quality metrics for ambulatory care in pediatric patients with tetralogy of Fallot.

PubMed

Villafane, Juan; Edwards, Thomas C; Diab, Karim A; Satou, Gary M; Saarel, Elizabeth; Lai, Wyman W; Serwer, Gerald A; Karpawich, Peter P; Cross, Russell; Schiff, Russell; Chowdhury, Devyani; Hougen, Thomas J

2017-12-01

The objective of this study was to develop quality metrics (QMs) relating to the ambulatory care of children after complete repair of tetralogy of Fallot (TOF). A workgroup team (WT) of pediatric cardiologists with expertise in all aspects of ambulatory cardiac management was formed at the request of the American College of Cardiology (ACC) and the Adult Congenital and Pediatric Cardiology Council (ACPC), to review published guidelines and consensus data relating to the ambulatory care of repaired TOF patients under the age of 18 years. A set of quality metrics (QMs) was proposed by the WT. The metrics went through a two-step evaluation process. In the first step, the RAND-UCLA modified Delphi methodology was employed and the metrics were voted on feasibility and validity by an expert panel. In the second step, QMs were put through an "open comments" process where feedback was provided by the ACPC members. The final QMs were approved by the ACPC council. The TOF WT formulated 9 QMs of which only 6 were submitted to the expert panel; 3 QMs passed the modified RAND-UCLA and went through the "open comments" process. Based on the feedback through the open comment process, only 1 metric was finally approved by the ACPC council. The ACPC Council was able to develop QM for ambulatory care of children with repaired TOF. These patients should have documented genetic testing for 22q11.2 deletion. However, lack of evidence in the literature made it a challenge to formulate other evidence-based QMs. © 2017 Wiley Periodicals, Inc.

Ambulatory pathway laser prostate surgery in severely ill patients--feasibility and short-term outcomes.

PubMed

Ingimarsson, Johann P; Herrick, Benjamin W; Yap, Ronald L

2014-03-01

To assess readmissions, complications, and outcomes of a rapid ambulatory discharge pathway (RADP) in high anesthetic risk patients who have undergone laser prostate surgery. Medical records of patients who underwent holmium laser ablation of the prostate between 2007 and 2012 by a single surgeon were retrospectively reviewed. Patients with American Society of Anesthesiologists category ≥3 ("severe systemic disease") were included. All patients were scheduled for a rapid ambulatory discharge pathway, which involved discharge on the day of surgery with a urethral catheter, with a voiding trial on postoperative day 3. Fifty-seven patients met the inclusion criteria. Fifty patients (88%) were successfully discharged on rapid ambulatory discharge pathway. Six patients (11%) were later readmitted for hematuria (3), urinary retention (1), or cardiac events (2). Two patients (4%) had emergency department visits for catheter-related problems. Increasing length of surgery, increasing amount of laser energy used, and a surgical indication indicative of more advanced disease were associated with postoperative hospitalization and readmissions on univariate analysis. No patient operated on for lower urinary tract symptoms was hospitalized or needed a readmission. The mean change in International Prostate Symptom Score and quality of life at 3 months were -12.5 ± 8.2 (P <.001) and -2.6 ± 1.7 (P <.001), respectively. It is safe to use a rapid ambulatory discharge pathway for laser prostatectomy in high anesthetic risk patients with good short-term outcomes, especially in men operated on for lower urinary tract symptoms. Copyright © 2014 Elsevier Inc. All rights reserved.

A Hot-Line Emergency Service for the Ambulatory Frail Elderly.

ERIC Educational Resources Information Center

Wolf-Klein, Gisele P.; Silverstone, Felix A.

1987-01-01

Surveyed patients and families who used hotline emergency service in ambulatory day treatment center for frail elderly. Results revealed appropriate use of service: Most calls required medical intervention, including hospitalization in 31 percent of cases. Findings suggest that 24-hour medical coverage is necessary and cost efficient. (Author/NB)

Commentary: quality of care and cost containment are the hospital-based ambulatory surgery challenges for the future.

PubMed

Frezza, E E; Girnys, R P; Silich, R J; Coppa, G F

2000-01-01

Cost containment and quality of care represent the most important objectives of all health care professionals. Because of its progressive growth over the past decade, ambulatory surgery has become an area where these 2 issues need to be addressed. The goal of this paper is to discuss the economic and quality of care challenges faced by hospitals as they strive to become competitive in the 21st century. The quality of care in ambulatory surgery has been improving because of multidisciplinary activities. Hospitals tend to hire the staff on the basis of their expertise in certain areas, and those personnel do not have to cover other hospital roles. Moreover, the hospital staff is able to seek information at any time from coworkers in other areas of specialty. Ambulatory surgery in a hospital offers advantages, such as multiple operating rooms, multiple skilled health care providers, and the ability to stay overnight if needed. The consolidation of supplies makes it easier to contract for a better price. Aggressive contract negotiations and implementation of cost-effective and cost-efficient strategies are the keys to success in the future. Quality improvement (QI) initiatives and quality of care (QC) indicators need to be developed to address various problems in the ambulatory surgery setting such as unnecessary admissions, inadequate staffing, efficient operating room (OR) utilization, quality of care, and assessment outcome. These initiatives should be addressed at regular meetings where opportunities to improve the ambulatory services are discussed. The number of ambulatory surgery procedures performed each year will continue to increase, although perhaps not at the rate we experienced in the past. Procedures that once were performed in an inpatient setting can now be accomplished on an outpatient basis or even in the physician's office. We will continue to see this shift of volume as technologic advancements and anesthetic agents allow more complex procedures to

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

Effects of an isocaloric healthy Nordic diet on ambulatory blood pressure in metabolic syndrome: a randomized SYSDIET sub-study.

PubMed

Brader, L; Uusitupa, M; Dragsted, L O; Hermansen, K

2014-01-01

Dietary pattern is central in the prevention of hypertension and blood pressure (BP)-related diseases. A diet based on healthy Nordic foods may have a favourable impact on BP. The objective was to clarify whether a Nordic alternative for a healthy food pattern would have beneficial effects on ambulatory BP in subjects with metabolic syndrome (MetS). In total, 37 subjects were randomized to either a healthy Nordic diet or a control diet. A healthy Nordic diet embraced whole grains, rapeseed oil, berries, fruits, vegetables, fish, nuts and low-fat dairy products of Nordic origin. The mean nutrient intake in the Nordic countries formed the control diet, embracing wheat products, dairy fat-based spread and a lower intake of fruits, vegetables and fish. Diets were isoenergetic. Ambulatory BP was monitored and 24-h urine was collected before and after 12 weeks of intervention. After 12 weeks, ambulatory diastolic BP (-4.4 mm Hg; P=0.001) and mean arterial pressure (-4.2 mm Hg; P=0.006) were lowered by the healthy Nordic diet compared with the control diet, whereas changes in ambulatory systolic BP did not differ significantly between diets (-3.5 mm Hg; P=0.122). Heart rate tended to be lower in those on the healthy Nordic diet (P=0.057). Urinary sodium and potassium excretions were unaffected by diets and consequently not associated with the healthy Nordic diet-induced lowering of BP. Consumption of Nordic varieties of health-enhancing foods for 12 weeks decreased diastolic ambulatory BP and mean arterial pressure in subjects with features of MetS during weight-stable condition, suggesting beneficial effects of a healthy Nordic dietary pattern on ambulatory BP.

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

PubMed Central

Shapiro, Daniel J.; Hersh, Adam L.

2011-01-01

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

Trends in the overuse of ambulatory health care services in the United States.

PubMed

Kale, Minal S; Bishop, Tara F; Federman, Alex D; Keyhani, Salomeh

2013-01-28

Given the rising costs of health care, policymakers are increasingly interested in identifying the inefficiencies in our health care system. The objective of this study was to determine whether the overuse and misuse of health care services in the ambulatory setting has decreased in the past decade. Cross-sectional analysis of the 1999 and 2009 National Ambulatory Medical Care Survey and the outpatient department component of the National Hospital Ambulatory Medical Care Survey, which are nationally representative annual surveys of visits to non-federally funded ambulatory care practices. We applied 22 quality indicators using a combination of current quality measures and guideline recommendations. The main outcome measures were the rates of underuse, overuse, and misuse and their 95% CIs. We observed a statistically significant improvement in 6 of 9 underuse quality indicators. There was an improvement in the use of antithrombotic therapy for atrial fibrillation; the use of aspirin, β-blockers, and statins in coronary artery disease; the use of β-blockers in congestive heart failure; and the use of statins in diabetes mellitus. We observed an improvement in only 2 of 11 overuse quality indicators, 1 indicator became worse, and 8 did not change. There was a statistically significant decrease in the overuse of cervical cancer screening in visits for women older than 65 years and in the overuse of antibiotics in asthma exacerbations. However, there was an increase in the overuse of prostate cancer screening in men older than 74 years. Of the 2 misuse indicators, there was a decrease in the proportion of patients with a urinary tract infection who were prescribed an inappropriate antibiotic. We found significant improvement in the delivery of underused care but more limited changes in the reduction of inappropriate care. With the high cost of health care, these results are concerning.

Ambulatory blood pressure monitoring-derived short-term blood pressure variability in primary hyperparathyroidism.

PubMed

Concistrè, A; Grillo, A; La Torre, G; Carretta, R; Fabris, B; Petramala, L; Marinelli, C; Rebellato, A; Fallo, F; Letizia, C

2018-04-01

Primary hyperparathyroidism is associated with a cluster of cardiovascular manifestations, including hypertension, leading to increased cardiovascular risk. The aim of our study was to investigate the ambulatory blood pressure monitoring-derived short-term blood pressure variability in patients with primary hyperparathyroidism, in comparison with patients with essential hypertension and normotensive controls. Twenty-five patients with primary hyperparathyroidism (7 normotensive,18 hypertensive) underwent ambulatory blood pressure monitoring at diagnosis, and fifteen out of them were re-evaluated after parathyroidectomy. Short-term-blood pressure variability was derived from ambulatory blood pressure monitoring and calculated as the following: 1) Standard Deviation of 24-h, day-time and night-time-BP; 2) the average of day-time and night-time-Standard Deviation, weighted for the duration of the day and night periods (24-h "weighted" Standard Deviation of BP); 3) average real variability, i.e., the average of the absolute differences between all consecutive BP measurements. Baseline data of normotensive and essential hypertension patients were matched for age, sex, BMI and 24-h ambulatory blood pressure monitoring values with normotensive and hypertensive-primary hyperparathyroidism patients, respectively. Normotensive-primary hyperparathyroidism patients showed a 24-h weighted Standard Deviation (P < 0.01) and average real variability (P < 0.05) of systolic blood pressure higher than that of 12 normotensive controls. 24-h average real variability of systolic BP, as well as serum calcium and parathyroid hormone levels, were reduced in operated patients (P < 0.001). A positive correlation of serum calcium and parathyroid hormone with 24-h-average real variability of systolic BP was observed in the entire primary hyperparathyroidism patients group (P = 0.04, P  = 0.02; respectively). Systolic blood pressure variability is increased in normotensive

Restructuring VA ambulatory care and medical education: the PACE model of primary care.

PubMed

Cope, D W; Sherman, S; Robbins, A S

1996-07-01

The Veterans Health Administration (VHA) Western Region and associated medical schools formulated a set of recommendations for an improved ambulatory health care delivery system during a 1988 strategic planning conference. As a result, the Department of Veterans Affairs (VA) Medical Center in Sepulveda, California, initiated the Pilot (now Primary) Ambulatory Care and Education (PACE) program in 1990 to implement and evaluate a model program. The PACE program represents a significant departure from traditional VA and non-VA academic medical center care, shifting the focus of care from the inpatient to the outpatient setting. From its inception, the PACE program has used an interdisciplinary team approach with three independent global care firms. Each firm is interdisciplinary in composition, with a matrix management structure that expands role function and empowers team members. Emphasis is on managed primary care, stressing a biopsychosocial approach and cost-effective comprehensive care emphasizing prevention and health maintenance. Information management is provided through a network of personal computers that serve as a front end to the VHA Decentralized Hospital Computer Program (DHCP) mainframe. In addition to providing comprehensive and cost-effective care, the PACE program educates trainees in all health care disciplines, conducts research, and disseminates information about important procedures and outcomes. Undergraduate and graduate trainees from 11 health care disciplines rotate through the PACE program to learn an integrated approach to managed ambulatory care delivery. All trainees are involved in a problem-based approach to learning that emphasizes shared training experiences among health care disciplines. This paper describes the transitional phases of the PACE program (strategic planning, reorganization, and quality improvement) that are relevant for other institutions that are shifting to training programs emphasizing primary and ambulatory care.

Physician ownership of ambulatory surgery centers and practice patterns for urological surgery: Evidence from the State of Florida

PubMed Central

Strope, Seth A.; Daignault, Stephanie; Hollingsworth, John M.; Ze, Zaujun; Wei, John T.; Hollenbeck, Brent K.

2009-01-01

Objective To evaluate the relationship between ownership and use of ambulatory surgical centers (ASCs). Methods From 1998 through 2002, ambulatory surgical discharges for procedures within the genitourinary system were abstracted from the Florida State Ambulatory Surgery Database. State-wide utilization rates for ambulatory surgery were calculated by physician-level ownership (using an empirically-derived, externally-validated method) and financial incentives. A surgeon level Poisson regression model was fit to compare the rates of surgery by year, ownership, and their interaction. Results Rates of ambulatory surgery increased from 607 per 100,000 in 1998 to 702 per 100,000 in 2002 (p < 0.01 for trend). While rates at the hospital increased only slightly (0.9%), those at the ASC were up by 53% (p < 0.01). Physician ownership was associated with this greater utilization as new owners increased their use from 9 per 100,000 to 94 per 100,000 (p < 0.01) in the first full year as owners. In the first year of ownership, the proportion of a new owner’s surgeries comprised of financially lucrative procedures increased to 61% compared to 50% in the year preceding ownership (p < 0.01). Conclusions Physician ownership is associated with the increasing use of ASCs, although the extent to which this is attributable to previously unmet demand is unclear. However, new owners appear to alter their procedure-mix after establishing ownership to include a greater share of financially lucrative procedures. PMID:19330889

Effect of losartan on ambulatory short-term blood pressure variability and cardiovascular remodeling in hypertensive patients on hemodialysis.

PubMed

Mitsuhashi, Hiroshi; Tamura, Kouichi; Yamauchi, Junji; Ozawa, Motoko; Yanagi, Mai; Dejima, Toru; Wakui, Hiromichi; Masuda, Shin-ichiro; Azuma, Koichi; Kanaoka, Tomohiko; Ohsawa, Masato; Maeda, Akinobu; Tsurumi-Ikeya, Yuko; Okano, Yasuko; Ishigami, Tomoaki; Toya, Yoshiyuki; Tokita, Yasuo; Ohnishi, Toshimasa; Umemura, Satoshi

2009-11-01

Previous studies have shown increases in ambulatory short-term blood pressure (BP) variability to be related to cardiovascular disease. In this study, we examined whether an angiotensin II type 1 receptor blocker losartan would improve ambulatory short-term BP variability in hypertensive patients on hemodialysis. Forty hypertensive patients on hemodialysis therapy were randomly assigned to the losartan treatment group (n=20) or the control treatment group (n=20). At baseline and 6 and 12 months after the treatment, 24-h ambulatory BP monitoring was performed. Echocardiography and measurements of brachial-ankle pulse wave velocity (baPWV) and biochemical parameters were also performed before and after therapy. After 6- and 12-months of treatment, nighttime short-term BP variability, assessed on the basis of the coefficient of variation of ambulatory BP, was significantly decreased in the losartan group, but remained unchanged in the control group. Compared with the control group, losartan significantly decreased left ventricular mass index (LVMI), baPWV, and the plasma levels of brain natriuretic peptide and advanced glycation end products (AGE). Furthermore, multiple regression analysis showed significant correlations between changes in LVMI and changes in nighttime short-term BP variability, as well as between changes in LVMI and changes in the plasma levels of AGE. These results suggest that losartan is beneficial for the suppression of pathological cardiovascular remodeling though its inhibitory effect on ambulatory short-term BP variability during nighttime.

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

Using administrative data to track fall-related ambulatory care services in the Veterans Administration Healthcare system.

PubMed

Luther, Stephen L; French, Dustin D; Powell-Cope, Gail; Rubenstein, Laurence Z; Campbell, Robert

2005-10-01

The Veterans Administration (VA) Healthcare system, containing hospital and community-based outpatient clinics, provides the setting for the study. Summary data was obtained from the VA Ambulatory Events Database for fiscal years (FY) 1997-2001 and in-depth data for FY 2001. In FY 2001, the database included approximately 4 million unique patients with 60 million encounters. The purpose of this study was: 1) to quantify injuries and use of services associated with falls among the elderly treated in Veterans Administration (VA) ambulatory care settings using administrative data; 2) to compare fall-related services provided to elderly veterans with those provided to younger veterans. Retrospective analysis of administrative data. This study describes the trends (FY 1997-2001) and patterns of fall-related ambulatory care encounters (FY 2001) in the VA Healthcare System. An approximately four-fold increase in both encounters and patients seen was observed in FY 1997-2001, largely paralleling the growth of VA ambulatory care services. More than two-thirds of the patients treated were found to be over the age of 65. Veterans over the age of 65 were found to be more likely to receive care in the non-urgent setting and had higher numbers of co-morbid conditions than younger veterans. While nearly half of the encounters occurred in the Emergency/Urgent Care setting, fall-related injuries led to services across a wide spectrum of medical and surgical providers/departments. This study represents the first attempt to use the VA Ambulatory Events Database to study fall-related services provided to elderly veterans. In view of the aging population served by the VA and the movement to provide increased services in the outpatient setting, this database provides an important resource for researchers and administrators interested in the prevention and treatment of fall-related injuries.

[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

[Ambulatory surgery--definition, socioeconomic and legal aspects].

PubMed

Hempel, K; Siewert, J R; Lehr, L

1995-04-01

One of the most important intentions of GSG 1992 is the favourization of traditional ambulatory surgery by legislative measures. However in general surgery a much higher potential for a significant reduction in cases of classical hospitalization and thus concomitant substantial financial savings lies in short-stay eg. one-day/one-night procedures. At present methods of laparoscopic cholecystectomy, thyroid surgery and herniorrhaphy-together about 50% of common hospital patients-are developed enough to be practiced safely under this strategy. In the future further suitable techniques could evolve from minor access surgical concepts.

Obtaining Reliable Estimates of Ambulatory Physical Activity in People with Parkinson's Disease.

PubMed

Paul, Serene S; Ellis, Terry D; Dibble, Leland E; Earhart, Gammon M; Ford, Matthew P; Foreman, K Bo; Cavanaugh, James T

2016-05-05

We determined the number of days required, and whether to include weekdays and/or weekends, to obtain reliable measures of ambulatory physical activity in people with Parkinson's disease (PD). Ninety-two persons with PD wore a step activity monitor for seven days. The number of days required to obtain a reliable estimate of daily activity was determined from the mean intraclass correlation (ICC2,1) for all possible combinations of 1-6 consecutive days of monitoring. Two days of monitoring were sufficient to obtain reliable daily activity estimates (ICC2,1 > 0.9). Amount (p = 0.03) but not intensity (p = 0.13) of ambulatory activity was greater on weekdays than weekends. Activity prescription based on amount rather than intensity may be more appropriate for people with PD.

[Simple and easy method for measurement of ambulatory activity in mice (author's transl)].

PubMed

Hirabayashi, M; Iizuka, M; Tadokoro, S

1978-07-01

A hand-made apparatus which is easily manipulative, cheap, durable and clean was used to measure ambulatory activity of a mouse. The apparatus was assembled with the same type of two plastic round basins commercially available (25 cm in diameter) put one upon another. A pivot was fixed at the center of the outsurface of the inner basin (A), and its open end was inserted into the open socket fixed at the center on the bottom of the outer basin (B). Three microswitches equipped on the brim of (B) at equal intervals were activated and the counts were recorded according to the tiltings of (A) through the movements of the mouse. In order to examine accuracy of the measurement, effects of d-amphetamine (1.25 approximately 5.0 mg/kg), methamphetamine (1.0 approximately 4.0 mg/kg), cocaine (10 approximately 40 mg/kg) and morphine (5.0 approximately 20.0 mg/kg) on the ambulatory activity were investigated. Marked accelerating effects were observed dose dependently after the administrations of all the drugs. Furthermore, the patterns of the activity showed characteristic properties of each drug. This method is especially useful to measure the acute effect of drugs on the ambulatory activity in mice, and many units can be set up at the same time.

Ambulatory surgery under local anesthesia for parathyroid adenoma: Feasibility and outcome.

PubMed

Benhami, A; Chuffart, E; Christou, N; Liva-Yonnet, S; Mathonnet, M

2017-12-21

The aim of this study was to evaluate the results of ambulatory parathyroid resection performed under local anesthesia (LA). Outpatients undergoing parathyroid adenoma resection by a focused approach under LA were included. Results were evaluated by intraoperative serum parathormone levels (ioPTH) and the balance of phosphate and calcium postoperatively, at 3 months, 1 year and at the point date. The quality of ambulatory care was evaluated by the number of cancelled interventions, the number of patients hospitalized after surgery or during the first postoperative month. The patient data manager of the institution carried out a medico-economic analysis. From 2005 to 2014, 129 patients met the inclusion criteria [women: 82% (sex ratio 1:5), median age: 72 years]. There was no morbidity for 98% of patients. Twelve patients had no statistically significant drop in ioPTH: two had persistent primary hyperparathyroidism (PHP). LA failed in four patients and PTH was late to normalize in six patients. Six patients had recurrent PHP (4.6%), of which two occurred four years after excision. Outpatient treatment was successful in 95%, without deprogramming or rehospitalization. The cost of the treatment under LA and on an outpatient basis was € 2014.90 (vs. € 2581.47 under general anesthesia and traditional hospitalization) CONCLUSION: Excision of single parathyroid adenomas can be performed under LA in an ambulatory setting without any major risk for the patient. The risk of recurrence after the focused approach requires regular laboratory monitoring for at least five years. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Exploring the business case for ambulatory electronic health record system adoption.

PubMed

Song, Paula H; McAlearney, Ann Scheck; Robbins, Julie; McCullough, Jeffrey S

2011-01-01

Widespread implementation and use of electronic health record (EHR) systems has been recognized by healthcare leaders as a cornerstone strategy for systematically reducing medical errors and improving clinical quality. However, EHR adoption requires a significant capital investment for healthcare providers, and cost is often cited as a barrier. Despite the capital requirements, a true business case for EHR system adoption and implementation has not been made. This is of concern, as the lack of a business case can influence decision making about EHR investments. The purpose of this study was to examine the role of business case analysis in healthcare organizations' decisions to invest in ambulatory EHR systems, and to identify what factors organizations considered when justifying an ambulatory EHR. Using a qualitative case study approach, we explored how five organizations that are considered to have best practices in ambulatory EHR system implementation had evaluated the business case for EHR adoption. We found that although the rigor of formal business case analysis was highly variable, informants across these organizations consistently reported perceiving that a positive business case for EHR system adoption existed, especially when they considered both financial and non-financial benefits. While many consider EHR system adoption inevitable in healthcare, this viewpoint should not deter managers from conducting a business case analysis. Results of such an analysis can inform healthcare organizations' understanding about resource allocation needs, help clarify expectations about financial and clinical performance metrics to be monitored through EHR systems, and form the basis for ongoing organizational support to ensure successful system implementation.

The use of ambulatory blood pressure monitoring to confirm a diagnosis of high blood pressure by primary-care physicians in Oregon.

PubMed

Carter, Brittany U; Kaylor, Mary Beth

2016-04-01

Hypertension is the most commonly diagnosed medical condition in the USA. Unfortunately, patients are misdiagnosed in primary care because of inaccurate office-based blood pressure measurements. Several US healthcare organizations currently recommend confirming an office-based hypertension diagnosis with ambulatory blood pressure monitoring to avoid overtreatment; however, its use for the purpose of confirming an office-based hypertension diagnosis is relatively unknown. This descriptive study surveyed 143 primary-care physicians in Oregon with regard to their current use of ambulatory blood pressure monitoring. Nineteen percent of the physicians reported that they would use ambulatory blood pressure monitoring to confirm an office-based hypertension diagnosis, although over half had never ordered it. The most frequent indication for ordering ambulatory blood pressure monitoring was to investigate suspected white-coat hypertension (37.3%). In addition, many of the practices did not own an ambulatory blood pressure monitoring device (79.7%) and, therefore, had to refer patients to other clinics or departments for testing. Many primary-care physicians will need to change their current clinical practice to align with the shift toward a confirmation process for office-based hypertension diagnoses to improve population health.

Persistent high job demands and reactivity to mental stress predict future ambulatory blood pressure.

PubMed

Steptoe, A; Cropley, M

2000-05-01

To test the hypothesis that work stress (persistent high job demands over 1 year) in combination with high reactivity to mental stress predict ambulatory blood pressure. Assessment of cardiovascular responses to standardized behavioural tasks, job demands, and ambulatory blood pressure over a working day and evening after 12 months. We studied 81 school teachers (26 men, 55 women), 36 of whom experienced persistent high job demands over 1 year, while 45 reported lower job demands. Participants were divided on the basis of high and low job demands, and high and low systolic pressure reactions to an uncontrollable stress task. Blood pressure and concurrent physical activity were monitored using ambulatory apparatus from 0900 to 2230 h on a working day. Cardiovascular stress reactivity was associated with waist/hip ratio. Systolic and diastolic pressure during the working day were greater in high job demand participants who were stress reactive than in other groups, after adjustment for age, baseline blood pressure, body mass index and negative affectivity. The difference was not accounted for by variations in physical activity. Cardiovascular stress reactivity and sustained psychosocial stress may act in concert to increase cardiovascular risk in susceptible individuals.

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

Factors Associated With Ambulatory Activity in De Novo Parkinson Disease.

PubMed

Christiansen, Cory; Moore, Charity; Schenkman, Margaret; Kluger, Benzi; Kohrt, Wendy; Delitto, Anthony; Berman, Brian; Hall, Deborah; Josbeno, Deborah; Poon, Cynthia; Robichaud, Julie; Wellington, Toby; Jain, Samay; Comella, Cynthia; Corcos, Daniel; Melanson, Ed

2017-04-01

Objective ambulatory activity during daily living has not been characterized for people with Parkinson disease prior to initiation of dopaminergic medication. Our goal was to characterize ambulatory activity based on average daily step count and examine determinants of step count in nonexercising people with de novo Parkinson disease. We analyzed baseline data from a randomized controlled trial, which excluded people performing regular endurance exercise. Of 128 eligible participants (mean ± SD = 64.3 ± 8.6 years), 113 had complete accelerometer data, which were used to determine daily step count. Multiple linear regression was used to identify factors associated with average daily step count over 10 days. Candidate explanatory variable categories were (1) demographics/anthropometrics, (2) Parkinson disease characteristics, (3) motor symptom severity, (4) nonmotor and behavioral characteristics, (5) comorbidities, and (6) cardiorespiratory fitness. Average daily step count was 5362 ± 2890 steps per day. Five factors explained 24% of daily step count variability, with higher step count associated with higher cardiorespiratory fitness (10%), no fear/worry of falling (5%), lower motor severity examination score (4%), more recent time since Parkinson disease diagnosis (3%), and the presence of a cardiovascular condition (2%). Daily step count in nonexercising people recruited for this intervention trial with de novo Parkinson disease approached sedentary lifestyle levels. Further study is warranted for elucidating factors explaining ambulatory activity, particularly cardiorespiratory fitness, and fear/worry of falling. Clinicians should consider the costs and benefits of exercise and activity behavior interventions immediately after diagnosis of Parkinson disease to attenuate the health consequences of low daily step count.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A170).

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

PubMed

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

2009-12-01

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

The Anxiolytic Effect of Aromatherapy on Patients Awaiting Ambulatory Surgery: A Randomized Controlled Trial

PubMed Central

Ni, Cheng-Hua; Hou, Wen-Hsuan; Kao, Ching-Chiu; Chang, Ming-Li; Yu, Lee-Fen; Wu, Chia-Che; Chen, Chiehfeng

2013-01-01

The aim of this study was to determine if aromatherapy could reduce preoperative anxiety in ambulatory surgery patients. A total of 109 preoperative patients were randomly assigned to experimental (bergamot essential oil) and control (water vapor) conditions and their responses to the State Trait Anxiety Inventory and vital signs were monitored. Patients were stratified by previous surgical experience, but that did not influence the results. All those exposed to bergamot essential oil aromatherapy showed a greater reduction in preoperative anxiety than those in the control groups. Aromatherapy may be a useful part of a holistic approach to reducing preoperative anxiety before ambulatory surgery. PMID:24454517

The Use of the Ambulatory Setting for Patient Self-Education.

ERIC Educational Resources Information Center

Newkirk, Gary; And Others

1979-01-01

A self-instructional health education program that utilizes a slide-tape device was studied to determine whether it could be educationally effective in an ambulatory clinical setting without being an inconvenience to patients. Infant and child nutrition was chosen as the topic to be used in the waiting room of a pediatric clinic. (JMD)

Interactive influences of ethnicity, endothelin-1 gene, and everyday discrimination upon nocturnal ambulatory blood pressure.

PubMed

Gregoski, Mathew J; Buxbaum, Sarah G; Kapuku, Gaston; Dong, Yanbin; Zhu, Haidong; Davis, Mary; Gonto, Kelsey; Treiber, Frank A

2013-06-01

Everyday discrimination scale scores are associated with increased ambulatory blood pressure (BP) and reduced nocturnal dipping, and the endothelin-1 (ET-1)/Lys198Asn polymorphism is associated with increased resting BP and exaggerated BP reactivity among African Americans compared to European Americans. Combined influences of these factors on BP control are unknown. This study tested the hypothesis of a three-way interaction between ethnicity, ET-1 carrier status, and everyday discrimination upon ambulatory BP and nocturnal dipping. Baseline laboratory anthropometrics and the everyday discrimination scale were completed by 352 (175 African American) young adult normotensives, followed by 24-h ambulatory BP monitoring. For nocturnal dipping, multiple regression models controlling for age, sex, ethnicity, and body mass index revealed significant three-way ET-1 × everyday discrimination × ethnicity interactions. Specifically, among African American ET-1 T-allele carriers, increases in everyday discrimination led to reduced nocturnal dipping. African Americans that carry the ET-1/Lys198Asn T-allele and report higher everyday discrimination scores may be at particular risk for reduced nocturnal dipping.

Interactive Influences of Ethnicity, Endothelin-1 Gene, and Everyday Discrimination Upon Nocturnal Ambulatory Blood Pressure

PubMed Central

Gregoski, Mathew J.; Buxbaum, Sarah G.; Kapuku, Gaston; Dong, Yanbin; Zhu, Haidong; Davis, Mary; Gonto, Kelsey; Treiber, Frank A.

2013-01-01

Background Everyday discrimination scale scores are associated with increased ambulatory blood pressure (BP), and reduced nocturnal dipping, and the ET-1/Lys198Asn polymorphism is associated with increased resting BP and exaggerated BP reactivity among African Americans compared to European Americans. Combined influences of these factors on BP control are unknown. Purpose This study tested the hypothesis of a three-way interaction between ethnicity, ET-1 carrier status and everyday discrimination upon ambulatory BP and nocturnal dipping. Methods Baseline laboratory anthropometrics and the everyday discrimination scale were completed by 351 (175 African American) young adult normotensives; followed by 24-hour ambulatory BP monitoring. Results For nocturnal dipping, multiple regression models controlling for age, sex, race, and BMI revealed significant three-way ET-1 x everyday discrimination x ethnicity interactions. Specifically, among African American ET-1 T-allele carriers, increases in everyday discrimination led to reduced nocturnal dipping. Conclusions African Americans that carry the ET1/Lys198Asn T-allele and report higher everyday discrimination scores may be at particular risk for reduced nocturnal dipping. PMID:23436272

Effective Learning in an Ambulatory Family Medicine Clerkship: A Qualitative Study of Medical Student Midpoint Feedback.

PubMed

Bradner, Melissa K; Flores, Sharon Kaufer; Gary, Judy S; Zumbrunn, Sharon

2017-09-01

There is substantial research on the effectiveness of ambulatory medical preceptors' teaching skills, but less is known about the student perspective on what contributes most to effective learning in a busy clinical practice. As part of a formative midpoint assessment during the third-year clerkship in family medicine, students were asked to respond to the following open-ended reflective prompt: "My preceptor contributed to my learning by..." A qualitative assessment of student responses was conducted to identify themes describing effective learning in the ambulatory setting. Responses for all clerkship students from the years 2012-2014 were examined (N=314). The most common characteristic of effective learning identified by respondents was Autonomy in Practice. Other prominent themes included Stimulating Critical Thinking and Feedback. Understanding student perceptions of the critical components of learning in ambulatory settings will allow medical educators to design meaningful student learning experiences and coach community teachers on effective teaching practices.

Knee Muscle Strength at Varying Angular Velocities and Associations with Gross Motor Function in Ambulatory Children with Cerebral Palsy

ERIC Educational Resources Information Center

Hong, Wei-Hsien; Chen, Hseih-Ching; Shen, I-Hsuan; Chen, Chung-Yao; Chen, Chia-Ling; Chung, Chia-Ying

2012-01-01

The aim of this study was to evaluate the relationships of muscle strength at different angular velocities and gross motor functions in ambulatory children with cerebral palsy (CP). This study included 33 ambulatory children with spastic CP aged 6-15 years and 15 children with normal development. Children with CP were categorized into level I (n =…

Use of Team-Based Learning Pedagogy for Internal Medicine Ambulatory Resident Teaching.

PubMed

Balwan, Sandy; Fornari, Alice; DiMarzio, Paola; Verbsky, Jennifer; Pekmezaris, Renee; Stein, Joanna; Chaudhry, Saima

2015-12-01

Team-based learning (TBL) is used in undergraduate medical education to facilitate higher-order content learning, promote learner engagement and collaboration, and foster positive learner attitudes. There is a paucity of data on the use of TBL in graduate medical education. Our aim was to assess resident engagement, learning, and faculty/resident satisfaction with TBL in internal medicine residency ambulatory education. Survey and nominal group technique methodologies were used to assess learner engagement and faculty/resident satisfaction. We assessed medical learning using individual (IRAT) and group (GRAT) readiness assurance tests. Residents (N = 111) involved in TBL sessions reported contributing to group discussions and actively discussing the subject material with other residents. Faculty echoed similar responses, and residents and faculty reported a preference for future teaching sessions to be offered using the TBL pedagogy. The average GRAT score was significantly higher than the average IRAT score by 22%. Feedback from our nominal group technique rank ordered the following TBL strengths by both residents and faculty: (1) interactive format, (2) content of sessions, and (3) competitive nature of sessions. We successfully implemented TBL pedagogy in the internal medicine ambulatory residency curriculum, with learning focused on the care of patients in the ambulatory setting. TBL resulted in active resident engagement, facilitated group learning, and increased satisfaction by residents and faculty. To our knowledge this is the first study that implemented a TBL program in an internal medicine residency curriculum.

Mood-congruent memory in daily life: evidence from interactive ambulatory monitoring.

PubMed

Loeffler, Simone N; Myrtek, Michael; Peper, Martin

2013-05-01

Evidence from the psychological laboratory indicates that emotional states tend to facilitate the encoding and retrieval of stimuli of the same emotional valence. To explore mood-congruent memory and the role of arousal in daily life, we applied a new interactive ambulatory technique. Psychophysiological arousal as indexed by non-metabolic heart rate, self-reported emotions and situational information were assessed during 24-h recordings in 70 healthy participants. The emotional state was used to trigger word list presentations on a minicomputer. Our results show that psychophysiological arousal at the time of encoding enhanced the recall of negative words in negative emotional conditions, whereas low psychophysiological arousal facilitated recall of positive words. In positive contexts, mood congruency was more prominent when arousal was low. These results demonstrate how automated experimentation with an ambulatory technique may help to assess emotional memory in real-world contexts, thus providing new methods for diverse fields of application. Copyright © 2013 Elsevier B.V. All rights reserved.

Ambulatory heart rate of professional taxi drivers while driving without their typical psychosocial work stressors: a pilot study.

PubMed

Choi, BongKyoo; Choi, SangJun; Jeong, JeeYeon; Lee, JiWon; Shu, Shi; Yu, Nu; Ko, SangBaek; Zhu, Yifang

2016-01-01

Few studies have examined ambulatory cardiovascular physiological parameters of taxi drivers while driving in relation to their occupational hazards. This study aims to investigate and quantify the impact of worksite physical hazards as a whole on ambulatory heart rate of professional taxi drivers while driving without their typical worksite psychosocial stressors. Ambulatory heart rate (HR driving ) of 13 non-smoking male taxi drivers (24 to 67 years old) while driving was continuously assessed on their 6-hour experimental on-road driving in Los Angeles. Percent maximum HR range (PMHR driving ) of the drivers while driving was estimated based on the individual HR driving values and US adult population resting HR (HR rest ) reference data. For analyses, the HR driving and PMHR driving data were split and averaged into 5-min segments. Five physical hazards inside taxi cabs were also monitored while driving. Work stress and work hours on typical work days were self-reported. The means of the ambulatory 5-min HR driving and PMHR driving values of the 13 drivers were 80.5 bpm (11.2 bpm higher than their mean HR rest ) and 10.7 % (range, 5.7 to 19.9 %), respectively. The means were lower than the upper limits of ambulatory HR and PMHR for a sustainable 8-hour work (35 bpm above HR rest and 30 % PMHR), although 15-27 % of the 5-min HR driving and PMHR driving values of one driver were higher than the limits. The levels of the five physical hazards among the drivers were modest: temperature (26.4 ± 3.0 °C), relative humidity (40.7 ± 10.4 %), PM 2.5 (21.5 ± 7.9  μg /m 3 ), CO 2 (1,267.1 ± 580.0 ppm) and noise (69.7 ± 3.0 dBA). The drivers worked, on average, 72 h per week and more than half of them reported that their job were often stressful. The impact of physical worksite hazards alone on ambulatory HR of professional taxi drivers in Los Angeles generally appeared to be minor. Future ambulatory heart rate studies including both

Persistent tachycardia in clozapine treated patients: A 24-hour ambulatory electrocardiogram study.

PubMed

Nilsson, Björn M; Lindström, Leif; Mohsen, Issam; Holmlöv, Karolina; Bodén, Robert

2018-03-27

Tachycardia is associated with cardiovascular mortality. Tachycardia is also a known clozapine adverse effect. However, whether clozapine-associated tachycardia is persistent is not known. Thirty clozapine-treated patients with clinical tachycardia were investigated with 24-hour ambulatory electrocardiography (ECG). Baseline peripheral heart rate (HR) was 106.7±7.8. The ambulatory ECG 24-hour-HR was 98.7±9.7. Baseline HR and 24-hour-HR correlated strongly (r=0.74, p=0.000003). Daytime HR was 106.4±9.9 and nighttime HR 89.2±12.0. Low dose bisoprolol reduced HR significantly. The high 24-hour-HR indicates a persistent tachycardia. Tachycardia should not discourage from clozapine use but the findings indicate a need of guidelines for detection and treatment of clozapine-associated tachycardia. Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.

Patterns of ambulatory care utilization in Taiwan.

PubMed

Chen, Tzeng-Ji; Chou, Li-Fang; Hwang, Shinn-Jang

2006-05-04

We used the insurance claims of a representative cohort to quantify the patterns of ambulatory care visits, especially the doctor-shopping phenomenon, in Taiwan. The ambulatory visit files of the 200,000-person cohort datasets from the National Health Insurance Research Database in 2002 were analyzed. Only a visit with physician consultation would be considered. We computed the visit patterns both by visit count and by patient count. In 2002, there were 182,474 eligible people with 2,443,003 physician consultations. During the year, 87.4% of the cohort had visited physician clinics and 57.5% had visited hospital-based outpatient or emergency departments. On average, a person had 13.4 physician consultations and consulted 3.4 specialties, 5.2 physicians, and 3.9 healthcare facilities in a year. In 2002, 17.3% of the cohort had ever visited different healthcare facilities on the same day; 23.5% had ever visited physicians of the same specialty at different healthcare facilities within 7 days and the percentage of second visits was 3.8% of all visits. Besides, 7.6% of the cohort had visited two or more specialties at the same facility on the same day, and such visits make up 2.5% of all visits. The people in Taiwan did visit the physicians and outpatient departments frequently. Many patients not only consulted several physicians of different specialties and at different healthcare facilities during the year, but also switched the physicians and facilities quickly. An effective referral system with efficient data exchange between facilities might be the solution.

[The scope and structure of ambulatory polyclinic visits of physicians in the Russian Federation in 2009-2011].

PubMed

Schepin, V O; Mirgorodskaya, O V

2013-01-01

The article presents the results of structural functional analysis of public statistic data concerning the appealability of population the Russian Federation for ambulatory polyclinic care in health institutions of Minzdrav of Russia in 2009-2011. The study was targeted to identify the institutions, the volume, the specialists, the groups of population and purpose of provided medical care. It is demonstrated that during three years the significant differences in volume and structure of ambulatory polyclinic care used per capita between adults and children, urban and rural residents still are present. This is an indication of different degree of need and availability of this kind of medical care. It is noted that in ambulatory polyclinic institutions the specialized medical care is provided mainly on the occasion of diseases. This situation is not fully in line with present conceptions of targets of this stage of medical care provision.

Perceived Racism and Ambulatory Blood Pressure in African American College Students

ERIC Educational Resources Information Center

Hill, LaBarron K.; Kobayashi, Ihori; Hughes, Joel W.

2007-01-01

Experiences with racial discrimination may contribute to stress-induced blood pressure (BP) elevations among African Americans. It was reported that perceived racism was associated with ambulatory BP (ABP) during waking hours. This study examined perceived racism and ABP among 40 African American college students, who completed an ABP assessment…

Psychological reactions to continuous ambulatory peritoneal dialysis.

PubMed

Geiser, M T; Van Dyke, C; East, R; Weiner, M

The first twenty patients who entered our continuous ambulatory peritoneal dialysis (CAPD) program from March, 1979 to February, 1981 were interviewed to assess their psychological reactions to CAPD. Six patients were successfully maintained on CAPD for more than one year. CAPD provided patients with a greater sense of well-being, strength, and independence. This independence required adherence to a strict schedule of exchanges. Reactions to the loss of CAPD followed the pattern of a grief reaction. Those patients who were self-disciplined and comfortable assuming active control of their health care proved to be the best candidates for CAPD.

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.

Endurance exercise beneficially affects ambulatory blood pressure: a systematic review and meta-analysis.

PubMed

Cornelissen, Véronique A; Buys, Roselien; Smart, Neil A

2013-04-01

Exercise is widely recommended as one of the key preventive lifestyle changes to reduce the risk of hypertension and to manage high blood pressure (BP), but individual studies investigating the effect of exercise on ambulatory BP have remained inconclusive. Therefore, the primary purpose of this systematic review and meta-analysis was to determine the effect of aerobic endurance training on daytime and night-time BP in healthy adults. A systematic literature search was conducted using PubMed and Cochrane Controlled Clinical trial registry from their inception to May 2012. Randomized controlled trials of at least 4 weeks investigating the effects of aerobic endurance training on ambulatory BP in healthy adults were included. Inverse weighted random effects models were used for analyses, with data reported as weighted means and 95% confidence limits. We included 15 randomized controlled trials, involving 17 study groups and 633 participants (394 exercise participants and 239 control participants). Overall, endurance training induced a significant reduction in daytime SBP [-3.2 mmHg, 95% confidence interval (CI), -5.0 to-1.3] and daytime DBP (-2.7 mmHg, 95% CI, -3.9 to -1.5). No effect was observed on night-time BP. The findings from this meta-analysis suggest that aerobic endurance exercise significantly decreases daytime, but not night-time, ambulatory BP.

[GPs' self-perception of their own role compared with hospital, ambulatory, academic, and health organisation physicians].

PubMed

Daghio, Maria Monica; Gaglianò, Giuseppe; Bevini, Massimo; Cadioli, Tiziano; Delvecchio, Carlo; Guidetti, Patrizia; Lorenzetti, Manuela; Fattori, Giuseppe; Ciardullo, Anna Vittoria

2005-05-01

Aim of the present study was to explore how the 76 general practitioners (GPs) - serving Carpi district (90,000 residents) - value their own role compared with the hospital, ambulatory, academic, and health organisation physicians'. GPs had a positive self-image only in comparison with health organisation doctors (7 vs 7 grades). GPs disappointed with themselves when comparing their role with ambulatory (-1.6 grades), academic (-1.9 grades) and hospital doctors (-2.2 grades). Secondarily, GPs perceived patients' valuing their professional role mostly 'subordinate' to the other physicians', except health organisation colleagues'.

Combined endovascular laser with ambulatory phlebectomy for the treatment of superficial venous incompetence: a 2-year perspective.

PubMed

Sadick, Neil S; Wasser, Samuel

2004-05-01

Non-invasive radiofrequency and endovascular technologies are becoming increasingly popular in the treatment of superficial venous incompetence. In conjunction with stab avulsion of truncal varicosities, these technologies have been able to address functional as well as cosmetic superficial venous incompetence in a non-invasive fashion. The present study presents a 2-year follow-up of 30 patients with combined axial incompetence of the greater saphenous vein (GSV) in conjunction with truncal varicosities treated with combination diode laser technology and ambulatory phlebectomy. Thirty patients (mean age 49 years) with Sapheno-Femoral Junction reflux associated with GSV incompetence (mean 9.2 x 8.5 mm) and enlarged branch varicosities, as documented by Duplex ultrasound, were enrolled. Patients were treated with an endovascular diode laser (810 nm, 14 W, continuous mode), followed by ambulatory phlebectomy of residual truncal varicosities. Patients were examined 3, 6, 12 and 24 months following this procedure to determine the long-term efficacy of this procedure. A 2-year closure rate of 96.8% was documented by Duplex evaluation. All 273 ambulatory phlebectomy vein segments were eradicated. Two cases of transient hyperpigmentation and one case of telangiectatic matting were documented. The combination of endovascular laser and ambulatory phlebectomy appear to be an effective and safe treatment approach for the management of combined saphenous and truncal varicose vein incompetence.

Ambulatory electrocardiography in car workers.

PubMed Central

Baxter, P J; White, W G; Barnes, G M; Cashman, P M

1978-01-01

A previous study in a car assembly plant showed that production-line workers had a lower incidence rate of heart attacks than executive staff. In the present study some major coronary risk factors and 24-hour ambulatory electrocardiograms were investigated in two age-matched samples of 30 middle-aged men drawn from these occupations. Men with a known history of heart disease were excluded. Compared with production-line workers, executive staff on average had a higher diastolic blood pressure (P less than 0.05) and fewer took heavy exercise during their leisure time (P less than 0.05). Ventricular premature beats (VPB was also similar for each of the periods of work, leisure and sleep. Apart from isolated ectopic beats, disturbances of rhythm were uncommon, and neither VPB nor other arrhythmias appeared to be induced by occupational factors. PMID:656344

A Guide to Assessing Ambulatory Health Care Needs in Your Community.

ERIC Educational Resources Information Center

Jones, Deborah; And Others

Designed for health services planners and decisionmakers on the local level, this guide describes and explains a relatively low-cost short-term approach by which communities can estimate their needs for ambulatory health care services, determine the adequacy of resources to meet those needs, and understand major factors for improving ambulatory…

A pilot audit of a protocol for ambulatory investigation of predicted low-risk patients with possible pulmonary embolism.

PubMed

McDonald, A H; Murphy, R

2011-09-01

Patients with possible pulmonary embolism (PE) commonly present to acute medical services. Research has led to the identification of low-risk patients suitable for ambulatory management. We report on a protocol designed to select low-risk patients for ambulatory investigation if confirmatory imaging is not available that day. The protocol was piloted in the Emergency Department and Medical Assessment Area at the Royal Infirmary of Edinburgh. We retrospectively analysed electronic patient records in an open observational audit of all patients managed in the ambulatory arm over five months of use. We analysed 45 patients' records. Of these, 91.1% required imaging to confirm or refute PE, 62.2% received a computed tomography pulmonary angiogram (CTPA). In 25% of patients, PE was confirmed with musculoskeletal pain (22.7%), and respiratory tract infection (15.9%) the next most prevalent diagnoses. Alternative diagnoses was provided by CTPA in 32% of cases. We identified no adverse events or readmissions but individualised follow-up was not attempted. The data from this audit suggests this protocol can be applied to select and manage low-risk patients suitable for ambulatory investigation of possible PE. A larger prospective comparative study would be required to accurately define the safety and effectiveness of this protocol.

Development of ACLEEM questionnaire, an instrument measuring residents' educational environment in postgraduate ambulatory setting.

PubMed

Riquelme, Arnoldo; Padilla, Oslando; Herrera, Cristian; Olivos, Trinidad; Román, José Antonio; Sarfatis, Alberto; Solís, Nancy; Pizarro, Margarita; Torres, Patricio; Roff, Sue

2013-01-01

Students' perceptions of their educational environment (EE) have been studied in undergraduate and postgraduate curricula. Postgraduate EE has been measured in hospital settings. However, there are no instruments available to measure the EE in postgraduate ambulatory settings. The aim of this study was to develop the "ambulatory care learning education environment measure" (ACLEEM). A mixed methodology was used including three stages: (1) Grounded theory (focus groups); (2) Delphi technique to identify consensus; and (3) Pilot study. Three quota samples of approximately 60 stakeholders were formed, one as focus groups and two as Delphi panels. Eight focus groups were carried out including 58 residents (Latin-American Spanish speakers). The results were analysed and 173 items were offered to a National Delphi panel (61 residents and teachers). They reduced in two rounds the number of important items to 54. The 54-item questionnaire was then piloted with 63 residents and refined to the final version of the ACLEEM with 50 items and three domains. The 50-item inventory is a valid instrument to measure the EE in postgraduate ambulatory setting in Chile. Large-scale administration of the ACLEEM questionnaire to evaluate its construct validity and reliability are the next steps to test the psychometric properties of the instrument.

Challenges in pediatric ambulatory anesthesia: kids are different.

PubMed

Collins, Corey E; Everett, Lucinda L

2010-06-01

The care of the child having ambulatory surgery presents a specific set of challenges to the anesthesia provider. This review focuses on areas of clinical distinction that support the additional attention children often require, and on clinical controversies that require providers to have up-to-date information to guide practice and address parental concerns. These include perioperative risk; obstructive sleep apnea; obesity; postoperative nausea and vomiting; neurocognitive outcomes; and specific concerns regarding common ear, nose, and throat procedures. Copyright (c) 2010 Elsevier Inc. All rights reserved.

AMBULATORY DIAGNOSIS AND TREATMENT OF NON-MALIGNANT PAIN IN THE UNITED STATES, 2000–2010

PubMed Central

Daubresse, Matthew; Chang, Hsien-Yen; Yu, Yuping; Viswanathan, Shilpa; Shah, Nilay D.; Stafford, Randall S.; Kruszewski, Stefan P.; Alexander, G. Caleb

2013-01-01

Background Escalating rates of prescription opioid use and abuse have occurred in the context of efforts to improve the treatment of non-malignant pain. Objectives To characterize the diagnosis and management of non-malignant pain in ambulatory, office-based settings in the United States between 2000 and 2010. Design, setting, and participants Serial cross-sectional and multivariate regression analyses of the National Ambulatory Medical Care Survey (NAMCS), a nationally representative audit of office-based physician visits. Measures (1) Annual visits volume among adults with primary pain symptom or diagnosis; (2) receipt of any pain treatment; and (3) receipt of prescription opioid or non-opioid pharmacologic therapy in visits for new musculoskeletal pain. Results Primary symptoms or diagnoses of pain consistently represented one-fifth of visits, varying little from 2000 through 2010. Among all pain visits, opioid prescribing nearly doubled from 11.3% to 19.6%, whereas non-opioid analgesic prescribing remained unchanged (26%–29% of visits). One-half of new musculoskeletal pain visits resulted in pharmacologic treatment, though the prescribing of non-opioid pharmacotherapies decreased from 38% of visits (2000) to 29% of visits (2010). After adjusting for potentially confounding covariates, few patient, physician or practice characteristics were associated with a prescription opioid rather than a non-opioid analgesic for new musculoskeletal pain, and increases in opioid prescribing generally occurred non-selectively over time. Conclusions Increased opioid prescribing has not been accompanied by similar increases in non-opioid analgesics or the proportion of ambulatory pain patients receiving pharmacologic treatment. Clinical alternatives to prescription opioids may be underutilized as a means of treating ambulatory non-malignant pain. PMID:24025657

Ambulatory blood pressure and heart rate during shuttle flight, entry and landing

NASA Technical Reports Server (NTRS)

Thornton, W.; Moore, T. P.; Uri, J.

1993-01-01

Ambulatory blood pressures (BP) and heart rates (HR) were recorded on a series of early Shuttle flights during preflight and pre-entry, entry, landing and egress. There were no significant differences between flight and preflight values during routine activity. Systolic blood pressure was slightly elevated in the deorbit period and systolic and diastolic blood pressure and heart rates were all elevated with onset of gravitoinertial loads and remained so through egress. Two of seven subjects had orthostatic problems in egress but their data did not show significant differences from others except in heart rate. Comparison of this data to that from recent studies show even larger increase in HR/BP values during current deorbit and entry phases which is consistent with increased heat and weight loads imposed by added survival gear. Both value and limitations of ambulatory heart rate/blood pressure data in this situation are demonstrated.

Ambulatory Resource Analysis Project Synopsis of Major Project Tasks,

DTIC Science & Technology

1992-01-02

January of 1992. These weights, developed by William Hsiao, PhD, at Harvard University School of Public Health, 1 t Medicare Program; Fee Schedule for...professional services fees and not facility costs. Without the facility cost data, the study focuses on the statistical properties of the group data and...and ambulatory surgery centers. There are three types of APG: (1) procedure, (2) ancillary service , and (3) medical. A key attribute of APGs is that

Optimising postoperative pain management in the ambulatory patient.

PubMed

Shang, Allan B; Gan, Tong J

2003-01-01

Over 60% of surgery is now performed in an ambulatory setting. Despite improved analgesics and sophisticated drug delivery systems, surveys indicate that over 80% of patients experience moderate to severe pain postoperatively. Inadequate postoperative pain relief can prolong recovery, precipitate or increase the duration of hospital stay, increase healthcare costs, and reduce patient satisfaction. Effective postoperative pain management involves a multimodal approach and the use of various drugs with different mechanisms of action. Local anaesthetics are widely administered in the ambulatory setting using techniques such as local injection, field block, regional nerve block or neuraxial block. Continuous wound infusion pumps may have great potential in an ambulatory setting. Regional anaesthesia (involving anaesthetising regional areas of the body, including single extremities, multiple extremities, the torso, and the face or jaw) allows surgery to be performed in a specific location, usually an extremity, without the use of general anaesthesia, and potentially with little or no sedation. Opioids remain an important component of any analgesic regimen in treating moderate to severe acute postoperative pain. However, the incorporation of non-opioids, local anaesthetics and regional techniques will enhance current postoperative analgesic regimens. The development of new modalities of treatment, such as patient controlled analgesia, and newer drugs, such as cyclo-oxygenase-2 inhibitors, provide additional choices for the practitioner. While there are different routes of administration for analgesics (e.g. oral, parenteral, intramuscular, transmucosal, transdermal and sublingual), oral delivery of medications has remained the mainstay for postoperative pain control. The oral route is effective, the simplest to use and typically the least expensive. The intravenous route has the advantages of a rapid onset of action and easier titratibility, and so is recommended for the

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…

Determinants of Slow Walking Speed in Ambulatory Patients Undergoing Maintenance Hemodialysis

PubMed Central

Matsuzawa, Ryota; Kutsuna, Toshiki; Yamamoto, Shuhei; Yoneki, Kei; Harada, Manae; Ishikawa, Ryoma; Watanabe, Takaaki; Yoshida, Atsushi

2016-01-01

Walking ability is significantly lower in hemodialysis patients compared to healthy people. Decreased walking ability characterized by slow walking speed is associated with adverse clinical events, but determinants of decreased walking speed in hemodialysis patients are unknown. The purpose of this study was to identify factors associated with slow walking speed in ambulatory hemodialysis patients. Subjects were 122 outpatients (64 men, 58 women; mean age, 68 years) undergoing hemodialysis. Clinical characteristics including comorbidities, motor function (strength, flexibility, and balance), and maximum walking speed (MWS) were measured and compared across sex-specific tertiles of MWS. Univariate and multivariate logistic regression analyses were performed to examine whether clinical characteristics and motor function could discriminate between the lowest, middle, and highest tertiles of MWS. Significant and common factors that discriminated the lowest and highest tertiles of MWS from other categories were presence of cardiac disease (lowest: odds ratio [OR] = 3.33, 95% confidence interval [CI] = 1.26–8.83, P<0.05; highest: OR = 2.84, 95% CI = 1.18–6.84, P<0.05), leg strength (OR = 0.62, 95% CI = 0.40–0.95, P<0.05; OR = 0.57, 95% CI = 0.39–0.82, P<0.01), and standing balance (OR = 0.76, 95% CI = 0.63–0.92, P<0.01; OR = 0.81, 95% CI = 0.68–0.97, P<0.05). History of fracture (OR = 3.35, 95% CI = 1.08–10.38; P<0.05) was a significant factor only in the lowest tertile. Cardiac disease, history of fracture, decreased leg strength, and poor standing balance were independently associated with slow walking speed in ambulatory hemodialysis patients. These findings provide useful data for planning effective therapeutic regimens to prevent decreases in walking ability in ambulatory hemodialysis patients. PMID:27018891

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

Intravenous Narcotic Antagonists in Ambulatory Oral Surgery

PubMed Central

Greenfield, William; Granada, Margarito G.

1975-01-01

Results of a study indicate that significant respiratory depression can be produced by the intravenous administration of narcotics in the anesthetic management of oral surgery patients. Naloxone hydrochloride reversed this reaction in all instances. Naloxone is a unique narcotic antagonist in that it does not possess agonistic properties of its own, it is effective in reversing respiratory depression resulting from all commonly used narcotics and narcotic antagonists, it causes no undesirable side effects, and it acts as a placebo when administered to a patient who has not had a narcotic. The use of naloxone should be considered when a potent narcotic is administered to an ambulatory patient. PMID:19598479

Ambulatory ECG monitoring in atrial fibrillation management.

PubMed

Rosero, Spencer Z; Kutyifa, Valentina; Olshansky, Brian; Zareba, Wojciech

2013-01-01

Ambulatory ECG monitoring technology has rapidly evolved over the last few decades and has been shown to identify life-threatening and non-life threatening arrhythmias and provide actionable data to guide clinical decision making. Atrial fibrillation episodes can often be asymptomatic, even after catheter ablation for atrial fibrillation, creating a disconnect between symptoms and actual arrhythmia burden which may alter clinical management. In this review, we aim to provide a comprehensive overview of invasive and non-invasive ECG monitoring strategies in patients with atrial fibrillation, with a special focus on the diagnosis of atrial fibrillation, and on follow-up of patients after catheter ablation for atrial fibrillation ablation. © 2013.

[Nutritional recovery of mild and moderately malnourished children under two different treatment approaches (ambulatory versus day-care)].

PubMed

Mariño, Mariana; Martínez, José; Azuaje, Arelis

2003-09-01

This retrospective analysis was conducted between May 1997 and May 2000 at the Centro de Atención Nutricional Infantil de Antímano, CANIA, in Caracas, Venezuela to assess the efficacy of two treatments (ambulatory versus day-care) of mild and moderate malnourished children. Inclusion criteria were: children under 10 years old with mild and moderate malnourishment, who attended a minimum of 3 control visits during a period of 12 months. One hundred fourteen malnourished children were included: fifty seven in ambulatory treatment and fifty seven in day-care treatment paired per nutritional diagnosis, gender and age (thirty nine mild and eighteen moderate malnourished children). The nutritional recovery criterion was weight for height above tenth percentile. No relation was found between treatment approaches and nutritional recovery at 3 and 6 months of treatment. In the group of mild malnourished children, the percentage of recovered patients at 3 months of treatment, that kept their recovered condition at 6 months was 83% (15/18) in the ambulatory treatment and 82% (18/22) in the day-care treatment Age of children, associated disease, acute morbidity, dietetic risk and mother's education and age were not associated with nutritional recovery at 6 months of treatment (p > 0.05). The day-care approach resulted as effective as ambulatory in mild malnourished children. In moderate malnourished new studies will need to be conducted with greater number of patients.

Clinical Significance of Postvoid Residual Volume in Older Ambulatory Women

PubMed Central

Huang, Alison J.; Brown, Jeanette S.; Boyko, Edward J.; Moore, Elya E.; Scholes, Delia; Walter, Louise C.; Lin, Feng; Vittinghoff, Eric; Fihn, Stephan D.

2013-01-01

Objectives To examine the prevalence, natural history, and clinical significance of elevations in postvoid residual (PVR) volume in ambulatory older women Design Prospective cohort study Setting Group health plan in Washington state Participants 987 ambulatory women aged 55 to 75 years Measurements PVR was measured by bladder ultrasonography at baseline, 1 year, and 2 years. Participants completed questionnaires about urinary symptoms and provided urine samples for microbiologic evaluation. Results Of the 987 participants, 79% had a PVR <50 mL, 10% had a PVR of 50–99 mL, 6% had a PVR of 100–199 mL, and 5% had a PVR ≥200 mL at baseline. Of women with a PVR <50, 66% reported at least one urinary symptom at baseline. Of women with a PVR ≥200 mL, 27% reported no significant symptoms at baseline. In adjusted analyses using data from all study visits, women with a PVR ≥100 mL were more likely to report urinating >8 times during the day (OR=1.42, CI=1.07–1.87), and women with a PVR ≥200 mL were more likely to report weekly urgency incontinence (OR=1.50, CI=1.03–2.18), versus those with a PVR <50 mL. Elevated PVR was not associated with increased risk of stress incontinence, nocturnal frequency, or urinary tract infection in adjusted analyses. Forty-six percent of those with a PVR ≥200 mL and 63% of those with a PVR of 100–199 mL at baseline had a PVR <50 mL at 2 years. Conclusion Over 10% of ambulatory older women may have a PVR ≥100 mL associated with increased risk of some urinary symptoms, but many with elevated PVR are asymptomatic, and elevations in PVR frequently resolve within 2 years. Symptom-guided management of urinary symptoms may be more appropriate than PVR-guided management in this population. PMID:21806559

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

Demographic and Treatment Patterns for Infections in Ambulatory Settings in the United States, 2006-2010

PubMed Central

May, Larissa; Mullins, Peter; Pines, Jesse

2013-01-01

Objectives Many factors may influence choice of care setting for treatment of acute infections. The authors evaluated a national sample of U.S. outpatient clinic and emergency department (ED) visits for three common infections (urinary tract infection [UTI], skin and soft tissue infection [SSTI], and upper respiratory infection [URI]), comparing setting, demographics, and care. Methods This was a retrospective analysis of 2006–2010 data from the National Hospital Ambulatory Care Survey (NHAMCS) and National Ambulatory Care Survey (NAMCS). Patients age ≥ 18 years with primary diagnoses of UTI, URI, and SSTI were the visits of interest. Demographics, tests, and prescriptions were compared, divided by ED versus outpatient setting using bivariate statistics. Results Between 2006 and 2010, there were an estimated 40.9 million ambulatory visits for UTI, 168.3 million visits for URI, and 34.8 million visits for SSTI; 24% of UTI, 11% of URI, and 33% of SSTI visits were seen in EDs. Across all groups, ED patients were more commonly younger and black and had Medicaid or no insurance. ED patients had more blood tests (54% vs. 22% for UTI, 21% vs. 14% for URI, and 25% vs. 20% for SSTI) and imaging studies (31% vs. 9% for UTI, 27% vs. 8% for URI, and 16% vs. 5% for SSTI). Pain medications were more frequently used in the ED; over one-fifth of UTI and SSTI visits included narcotics. In both settings, greater than 50% of URI visits received antibiotics; more than 40% of UTI ED visits included broad-spectrum fluoroquinolones. Conclusions Emergency departments treated a considerable proportion of U.S. ambulatory infections from 2006 to 2010. Patient factors, including the presence of acute pain and access to care, appear to influence choice of care setting. Observed antibiotic use in both settings suggests a need for optimizing antibiotic use. PMID:24552520

Latissimus dorsi free flap for coverage of sacral radiodermatitis in the ambulatory patient

DOE Office of Scientific and Technical Information (OSTI.GOV)

Stark, D.; Tofield, J.J.; Terranova, W.

1987-07-01

Ambulatory patients with large sacral ulcers can represent extremely challenging coverage problems. Technical options become fewer when sacral ulcers are coupled with radiation dermatitis. Latissimus dorsi free flap transfer, with direct anastomoses to sacral vessels, is described in 2 patients.

High Prevalence of Obesity in Ambulatory Children and Adolescents with Intellectual Disability

ERIC Educational Resources Information Center

Stewart, L.; Van de Ven, L.; Katsarou, V.; Rentziou, E.; Doran, M.; Jackson, P.; Reilly, J. J.; Wilson, D.

2009-01-01

Background: Obesity prevalence is unusually high among adults with intellectual disability (ID). There is limited and conflicting evidence on obesity prevalence among ambulatory children and adolescents with ID. The present study aimed to estimate obesity prevalence in this group and to compare with population prevalence. Methods: Survey of nine…

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

Ambulatory combined pH, bile and manometric monitoring of the oesophagus in asymptomatic healthy volunteers.

PubMed

Freedman, Jacob; Lindqvist, Madeleine; Melcher, Anders; Granström, Lars; Näslund, Erik

2004-11-01

With the development of sophisticated equipment ambulatory studies of oesophageal motor function, pH and bilirubin have gained in popularity. The aim of the study was to present reference values for combined 24 h pH, bilirubin and manometric measurements of the oesophagus. Twenty-six (15 male) healthy volunteers without symptoms of gastro-oesophageal reflux underwent a 24-h ambulatory oesophageal combined three-channel pressure, acid and bilirubin detection. The subjects were studied for a median of 20 h (16-22). The median per cent time with pH < 4 for the whole measured time was 3.1 (0.8-14; 5 and 95 percentiles). Bile was detected for a median of 0.05% (0.0-8.5; 5 and 95 percentiles) of the time. Eighty-one per cent of the contractions were peristaltic, 55% of which were complete. Of these, 53% had a pressure over 30 mmHg at all three pressure points, giving an efficient peristalsis in a median of 29% (13-46; 5 and 95 percentiles) of all registered contractile patterns. No difference between the genders could be observed. This study provides normative data for ambulatory oesophageal manometry, pH and bilirubin studies that can be used for comparing with patients with disease.

The Ambulatory Care Workload Management System for Nursing Reference Manual

DTIC Science & Technology

1991-05-31

MEDICAL DATA SERVICES CENTER BETHESDA, MARYLAND 2088Q-506. 91-03029 SECuRItY CLASSIFICATION OF THIS PAGEr REPORT DOCUMENTATION PAGE Ia. REPORT SECURITY...ORGANIZATION 6b OFFICE SYMBOL 7a. NAME OF MONITORING ORGANIZATION Naval Medical Data Servics (If applicable) Center 6c. ADDRESS (City, State, and ZIPCode) 7b...staffing methodology developed for emergency and ambulatory care departments in naval medical treatment facilities . The staffing model translates varying

Optimizing the Design of Preprinted Orders for Ambulatory Chemotherapy: Combining Oncology, Human Factors, and Graphic Design

PubMed Central

Jeon, Jennifer; White, Rachel E.; Hunt, Richard G.; Cassano-Piché, Andrea L.; Easty, Anthony C.

2012-01-01

Purpose: To establish a set of guidelines for developing ambulatory chemotherapy preprinted orders. Methods: Multiple methods were used to develop the preprinted order guidelines. These included (A) a comprehensive literature review and an environmental scan; (B) analyses of field study observations and incident reports; (C) critical review of evidence from the literature and the field study observation analyses; (D) review of the draft guidelines by a clinical advisory group; and (E) collaboration with graphic designers to develop sample preprinted orders, refine the design guidelines, and format the resulting content. Results: The Guidelines for Developing Ambulatory Chemotherapy Preprinted Orders, which consist of guidance on the design process, content, and graphic design elements of ambulatory chemotherapy preprinted orders, have been established. Conclusion: Health care is a safety critical, dynamic, and complex sociotechnical system. Identifying safety risks in such a system and effectively addressing them often require the expertise of multiple disciplines. This study illustrates how human factors professionals, clinicians, and designers can leverage each other's expertise to uncover commonly overlooked patient safety hazards and to provide health care professionals with innovative, practical, and user-centered tools to minimize those hazards. PMID:23077436

Optimizing the design of preprinted orders for ambulatory chemotherapy: combining oncology, human factors, and graphic design.

PubMed

Jeon, Jennifer; White, Rachel E; Hunt, Richard G; Cassano-Piché, Andrea L; Easty, Anthony C

2012-03-01

To establish a set of guidelines for developing ambulatory chemotherapy preprinted orders. Multiple methods were used to develop the preprinted order guidelines. These included (A) a comprehensive literature review and an environmental scan; (B) analyses of field study observations and incident reports; (C) critical review of evidence from the literature and the field study observation analyses; (D) review of the draft guidelines by a clinical advisory group; and (E) collaboration with graphic designers to develop sample preprinted orders, refine the design guidelines, and format the resulting content. The Guidelines for Developing Ambulatory Chemotherapy Preprinted Orders, which consist of guidance on the design process, content, and graphic design elements of ambulatory chemotherapy preprinted orders, have been established. Health care is a safety critical, dynamic, and complex sociotechnical system. Identifying safety risks in such a system and effectively addressing them often require the expertise of multiple disciplines. This study illustrates how human factors professionals, clinicians, and designers can leverage each other's expertise to uncover commonly overlooked patient safety hazards and to provide health care professionals with innovative, practical, and user-centered tools to minimize those hazards.

The Ambulatory Experience for Junior Medical Students at the Medical College of Georgia.

ERIC Educational Resources Information Center

Fincher, Ruth-Marie E.; Albritton, T. Andrew

1993-01-01

The Medical College of Georgia's third-year medicine clerkship includes a one-month ambulatory care block rotation in internal medicine, medicine, and dermatology. Students present topics and participate in case discussions in daily and weekly conferences. Program success is resulting in expansion. (MSE)

Ambulatory Arterial Stiffness Indexes in Cushing's Syndrome.

PubMed

Battocchio, Marialberta; Rebellato, Andrea; Grillo, Andrea; Dassie, Francesca; Maffei, Pietro; Bernardi, Stella; Fabris, Bruno; Carretta, Renzo; Fallo, Francesco

2017-03-01

Long-standing exposure to endogenous cortisol excess is associated with high cardiovascular risk. The aim of our study was to investigate arterial stiffness, which has been recognized as an independent predictor of adverse cardiovascular outcome, in a group of patients with Cushing's syndrome. Twenty-four patients with Cushing's syndrome (3 males, mean age 49±13 years; 20 pituitary-dependent Cushing's disease and 4 adrenal adenoma) underwent 24-h ambulatory blood pressure monitoring (ABPM) and evaluation of cardiovascular risk factors. The Ambulatory Arterial Stiffness Index (AASI) and symmetric AASI (sAASI) were derived from ABPM tracings. Cushing patients were divided into 8 normotensive (NOR-CUSH) and 16 hypertensive (HYP-CUSH) patients, and were compared with 8 normotensive (NOR-CTR) and 16 hypertensive (HYP-CTR) control subjects, matched for demographic characteristics, 24-h ABPM and cardiometabolic risk factors. The AASI and sAASI indexes were significantly higher in Cushing patients than in controls, either in the normotensive (p=0.048 for AASI and p=0.013 for sAASI) or in the hypertensive (p=0.004 for AASI and p=0.046 for sAASI) group. No difference in metabolic parameters was observed between NOR-CUSH and NOR-CTR or between HYP-CUSH and HYP-CTR groups. AASI and sAASI were both correlated with urinary cortisol in patients with endogenous hypercortisolism (Spearman's rho=0.40, p=0.05, and 0.61, p=0.003, respectively), while no correlation was found in controls. Both AASI and sAASI are increased in Cushing syndrome, independent of BP elevation, and may represent an additional cardiovascular risk factor in this disease. The role of excess cortisol in arterial stiffness has to be further clarified. © Georg Thieme Verlag KG Stuttgart · New York.

Funding of tribal health programs linked to lower rates of hospitalization for conditions sensitive to ambulatory care.

PubMed

Korenbrot, Carol; Kao, Chi; Crouch, James A

2009-01-01

To determine first whether higher funding of Tribally Operated Health Programs (TOHP) is associated with reduced hospitalizations for ambulatory care sensitive conditions (HASC) of the American Indian/Alaska Natives (AIAN) who use them after adjusting for characteristics of TOHP service areas; and then whether improved ambulatory care with higher levels of funding mediates the association. Records in the Indian Health Service (IHS) for California of an annual average 42,153 AIAN users of TOHP from 1998 to 2002 were linked with state hospital discharge records. We analyzed 3181 HASC for AIAN users of 20 TOHP in multilevel Poisson regression models to determine the association of HASC rates adjusted for individual age and gender with the Federal Disparity Index for IHS funding of TOHP. Higher IHS funding of TOHP was associated with lower HASC rates for the AIAN who use them. For TOHP with less than 60% of health care costs funded, the HASC rate dropped 12% for every increase of 10% in funding. Even adjusting for characteristics of the service areas, the effect was only slightly reduced to a value of 9% to 11%. None of the available indicators of ambulatory care tested were found to mediate the effects. Our findings are consistent with a policy of IHS funding of all TOHP at a level of at least 60% of the health care costs of the AIAN who use the programs, instead of the current policy of 40%. Additional research is needed to understand what ambulatory care characteristics are improved by the funding.

Asymptomatic deep vein thrombosis and superficial vein thrombosis in ambulatory cancer patients: impact on short-term survival

PubMed Central

Gary, T; Belaj, K; Steidl, K; Pichler, M; Eisner, F; Stöger, H; Hafner, F; Froehlich, H; Samonigg, H; Pilger, E; Brodmann, M

2012-01-01

Background: Asymptomatic venous thrombotic events (VTEs) are possible findings in ambulatory cancer patients. Data regarding the incidence and clinical impact of asymptomatic VTEs are conflicting. We therefore conducted a study to evaluate the occurrence of asymptomatic VTEs of the lower limbs in ambulatory cancer patients to further evaluate the association of these asymptomatic VTEs on survival during a 9-month follow-up period. Methods: In our prospective cohort, we included 150 consecutive ambulatory cancer patients who were free of any clinical symptoms for VTEs. Compression ultrasound to detect deep vein thrombosis (DVT) and superficial venous thrombosis (SVT) of the lower limbs was performed by a vascular specialist in all patients at baseline. In case of pathological findings the patients were treated with low molecular weight heparin (LMWH) because of current established guidelines. The occurrence of death was investigated during a 9-month follow-up period. Results: A total of 27 (18%) patients with VTEs were detected, which included 13 patients (8.7%) with a SVT and 16 patients (10.7%) showing a DVT. Two patients had both, a SVT and a DVT as well. During the 9-month follow-up period the occurrence of a VTE at baseline was associated with a 2.4-fold increased risk for death (HR 2.4 (1.2–5.3); P=0.03). Conclusion: Asymptomatic VTEs of the lower limbs in ambulatory cancer patients are frequently occurring concomitant features and are associated with poor survival during a 9-month follow-up period despite anticoagulation with LMWH. PMID:22968652

New utility for an old tool: can a simple gait speed test predict ambulatory surgical discharge outcomes?

PubMed

Odonkor, Charles A; Schonberger, Robert B; Dai, Feng; Shelley, Kirk H; Silverman, David G; Barash, Paul G

2013-10-01

The primary aims of this study were to design prediction models based on a functional marker (preoperative gait speed) to predict readiness for home discharge time of 90 mins or less and to identify those at risk for unplanned admissions after elective ambulatory surgery. This prospective observational cohort study evaluated all patients scheduled for elective ambulatory surgery. Home discharge readiness and unplanned admissions were the primary outcomes. Independent variables included preoperative gait speed, heart rate, and total anesthesia time. The relationship between all predictors and each primary outcome was determined in separate multivariable logistic regression models. After adjustment for covariates, gait speed with adjusted odds ratio of 3.71 (95% confidence interval, 1.21-11.26), P = 0.02, was independently associated with early home discharge readiness of 90 mins or less. Importantly, gait speed dichotomized as greater or less than 1 m/sec predicted unplanned admissions, with odds ratio of 0.35 (95% confidence interval, 0.16-0.76, P = 0.008) for those with speeds 1 m/sec or greater in comparison with those with speeds less than 1 m/sec. In a separate model, history of cardiac surgery with adjusted odds ratio of 7.5 (95% confidence interval, 2.34-24.41; P = 0.001) was independently associated with unplanned admissions after elective ambulatory surgery, when other covariates were held constant. This study demonstrates the use of novel prediction models based on gait speed testing to predict early home discharge and to identify those patients at risk for unplanned admissions after elective ambulatory surgery.

Ambulatory Activity of Children with Cerebral Palsy: Which Characteristics Are Important?

ERIC Educational Resources Information Center

van Wely, Leontien; Becher, Jules G.; Balemans, Astrid C. J.; Dallmeijer, Annet J.

2012-01-01

Aim: To assess ambulatory activity of children with cerebral palsy (CP), aged 7 to 13 years, and identify associated characteristics. Method: Sixty-two children with spastic CP (39 males, 23 females; mean age 10y 1mo, SD 1y 8mo; age range 7-13y), classified as Gross Motor Function Classification System (GMFCS) levels I to III, participated.…

Automatic detection of respiration rate from ambulatory single-lead ECG.

PubMed

Boyle, Justin; Bidargaddi, Niranjan; Sarela, Antti; Karunanithi, Mohan

2009-11-01

Ambulatory electrocardiography is increasingly being used in clinical practice to detect abnormal electrical behavior of the heart during ordinary daily activities. The utility of this monitoring can be improved by deriving respiration, which previously has been based on overnight apnea studies where patients are stationary, or the use of multilead ECG systems for stress testing. We compared six respiratory measures derived from a single-lead portable ECG monitor with simultaneously measured respiration air flow obtained from an ambulatory nasal cannula respiratory monitor. Ten controlled 1-h recordings were performed covering activities of daily living (lying, sitting, standing, walking, jogging, running, and stair climbing) and six overnight studies. The best method was an average of a 0.2-0.8 Hz bandpass filter and RR technique based on lengthening and shortening of the RR interval. Mean error rates with the reference gold standard were +/-4 breaths per minute (bpm) (all activities), +/-2 bpm (lying and sitting), and +/-1 breath per minute (overnight studies). Statistically similar results were obtained using heart rate information alone (RR technique) compared to the best technique derived from the full ECG waveform that simplifies data collection procedures. The study shows that respiration can be derived under dynamic activities from a single-lead ECG without significant differences from traditional methods.

Pathways linking major depression and immunity in ambulatory female patients.

PubMed

Miller, G E; Cohen, S; Herbert, T B

1999-01-01

The goals of this study were to investigate whether depression is associated with cellular immunity in ambulatory patients and to identify neuroendocrine and behavioral pathways that might account for this relationship. We studied 32 women who met Diagnostic and Statistical Manual of Mental Disorder, fourth edition, criteria for major depressive disorder and 32 healthy female control subjects. The groups were matched for age and ethnicity. None were taking medication, and all were free of disease involving the immune system. Depressed subjects had reduced proliferative responses to the mitogens concanavalin A and phytohemagglutinin compared with control subjects. Natural killer cell activity was reduced among older depressed subjects but enhanced among younger depressed subjects. Although depression was associated with elevated circulating levels of norepinephrine and estradiol, these hormones could not account for the immunologic differences between depressed and control subjects. Depression was also associated with greater tobacco and caffeine consumption, less physical activity, and poorer sleep quality. Mediational analyses were consistent with physical activity acting as a pathway through which depression was associated with reduced lymphocyte proliferation. Ambulatory patients with mild to moderately severe depression exhibit reduced mitogen-stimulated lymphocyte proliferative responses and altered natural killer cell cytotoxicity. The relationship between depression and proliferative responses may be mediated by physical activity.

Influence of lightweight ambulatory oxygen on oxygen use and activity patterns of COPD patients receiving long-term oxygen therapy.

PubMed

Casaburi, Richard; Porszasz, Janos; Hecht, Ariel; Tiep, Brian; Albert, Richard K; Anthonisen, Nicholas R; Bailey, William C; Connett, John E; Cooper, J Allen; Criner, Gerard J; Curtis, Jeffrey; Dransfield, Mark; Lazarus, Stephen C; Make, Barry; Martinez, Fernando J; McEvoy, Charlene; Niewoehner, Dennis E; Reilly, John J; Scanlon, Paul; Scharf, Steven M; Sciurba, Frank C; Woodruff, Prescott

2012-02-01

Lightweight ambulatory oxygen devices are provided on the assumptions that they enhance compliance and increase activity, but data to support these assumptions are lacking. We studied 22 patients with severe chronic obstructive pulmonary disease receiving long-term oxygen therapy (14 men, average age = 66.9 y, FEV(1) = 33.6%pred, PaO(2) at rest = 51.7 torr) who were using E-cylinders as their portable oxygen. Subjects were recruited at 5 sites and studied over a 2-week baseline period and for 6 months after randomizing them to either continuing to use 22-lb E-cylinders towed on a cart or to carrying 3.6-lb aluminum cylinders. Utilizing novel electronic devices, ambulatory and stationary oxygen use was monitored continuously over the 2 weeks prior to and the 6 months following randomization. Subjects wore tri-axial accelerometers to monitor physical activity during waking hours for 2-3 weeks prior to, and at 3 and 6 months after, randomization. Seventeen subjects completed the study. At baseline, subjects used 17.2 hours of stationary and 2.5 hours of ambulatory oxygen daily. At 6 months, ambulatory oxygen use was 1.4 ± 1.0 hrs in those randomized to E-cylinders and 1.9 ± 2.4 hrs in those using lightweight oxygen (P = NS). Activity monitoring revealed low activity levels prior to randomization and no significant increase over time in either group. In this group of severe chronic obstructive pulmonary disease patients, providing lightweight ambulatory oxygen did not increase either oxygen use or activity. Future efforts might focus on strategies to encourage oxygen use and enhance activity in this patient group. This trial is registered at ClinicalTrials.gov (NCT003257540).

Socioeconomic characteristics of patients undergoing ambulatory diagnostic cerebral angiography in four US States.

PubMed

Bekelis, K; Missios, S; Eskey, C; Labropoulos, N

2014-02-01

Several groups have demonstrated the safety of ambulatory cerebral angiography, with no patients experiencing complications related to early discharge. Although this practice appears to be safe, the socioeconomic characteristics factoring in the selection of the patients have not been investigated. We performed a retrospective cohort study involving 45,226 patients undergoing outpatient and 159,046 undergoing inpatient cerebral angiography, who were registered in the State Ambulatory Surgery Databases (SASD) and State Inpatient Databases (SID) respectively for 4 US States (New York, California, Florida, North Carolina). In a multivariate analysis of diagnostic cerebral angiography, Caucasian race (OR 1.36, 95% CI, 1.31, 1.42) and male gender (OR 1.36, 95% CI, 1.31, 1.41), were significantly associated with outpatient procedures. Higher Charlson Comorbidity Index (CCI) (OR 0.60, 95% CI, 0.54, 0.67), high income (OR 0.70, 95% CI, 0.67, 0.73), high volume hospitals (OR 0.69, 95% CI, 0.66, 0.73), and coverage by Medicare/Medicaid (OR 0.96, 95% CI, 0.92, 0.99) were associated with a decreased chance of outpatient procedures. Institutional charges were significantly less for outpatient cerebral angiography. The median charge for inpatient diagnostic cerebral angiography was $26,968 as compared to $16,151 in the outpatient setting (P < 0.0001, Student's t-test). Access to ambulatory diagnostic cerebral angiography appears to be more common for patients with private insurance and less comorbidities, in the setting of lower volume hospitals. Further investigation is needed in the direction of mapping these disparities in resource utilization.

Inactive and sedentary lifestyles amongst ambulatory adolescents and young adults with cerebral palsy

PubMed Central

2014-01-01

Background To assess physical behaviour, including physical activity and sedentary behaviour, of ambulatory adolescents and young adults with cerebral palsy (CP). We compared participant physical behaviour to that of able-bodied persons and assessed differences related to Gross Motor Functioning Classification System (GMFCS) level and CP distribution (unilateral/bilateral). Methods In 48 ambulatory persons aged 16 to 24 years with spastic CP and in 32 able-bodied controls, physical behaviour was objectively determined with an accelerometer-based activity monitor. Total duration, intensity and type of physical activity were assessed and sedentary time was determined (lying and sitting). Furthermore, distribution of walking bouts and sitting bouts was specified. Results Adolescents and young adults with CP spent 8.6% of 24 hours physically active and 79.5% sedentary, corresponding with respectively 123 minutes and 1147 minutes per 24 hours. Compared to able-bodied controls, persons with CP participated 48 minutes less in physical activities (p < 0.01) and spent 80 minutes more sedentary per 24 hours (p < 0.01). Physical behaviour was not different between persons with GMFCS level I and II and only number of short sitting bouts were significantly more prevalent in persons with bilateral CP compared to unilateral CP (p < 0.05). Conclusions Ambulatory adolescents and young adults with CP are less physically active and spend more time sedentary compared to able-bodied persons, suggesting that this group may be at increased risk for health problems related to less favourable physical behaviour. Trial registration Nederlands trial register: NTR1785 PMID:24708559

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.

[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.

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

PubMed

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

1999-12-11

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

A systematic review of risk factors associated with accidental falls, outcome measures and interventions to manage fall risk in non-ambulatory adults.

PubMed

Rice, Laura A; Ousley, Cherita; Sosnoff, Jacob J

2015-01-01

To systematically review peer-reviewed literature pertaining to risk factors, outcome measures and interventions managing fall risk in non-ambulatory adults. Twenty-one papers were selected for inclusion from databases including PubMed/Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Scopus, Consumer Health Complete and Web of Science. Selected studies involved a description of fall related risk factors, outcomes to assess fall risk and intervention studies describing protocols to manage fall risk in non-ambulatory adults. Studies were selected by two reviewers and consultation provided by a third reviewer. The most frequently cited risk factors/characteristics associated with falls included: wheelchair related characteristics, transfer activities, impaired seated balance and environmental factors. The majority of the outcomes were found to evaluate seated postural control. One intervention study was identified describing a protocol targeting specific problems of individual participants. A global fall prevention program was not identified. Several risk factors associated with falls were identified and must be understood by clinicians to better serve their clients. To improve objective assessment, a comprehensive outcome assessment specific to non-ambulatory adults is needed. Finally, additional research is needed to examine the impact of structured protocols to manage fall risk in non-ambulatory adults. Falls are a common health concern for non-ambulatory adults. Risk factors commonly associated with falls include wheelchair related characteristics, transfer activities, impaired seated balance and environmental factors. Limited outcome measures are available to assess fall risk in non-ambulatory adults. Clinicians must be aware of the known risk factors and provide comprehensive education to their clients on the potential for falls. Additional research is needed to develop and evaluate protocols to clinically manage fall

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

Evaluative threat and ambulatory blood pressure: cardiovascular effects of social stress in daily experience.

PubMed

Smith, Timothy W; Birmingham, Wendy; Uchino, Bert N

2012-11-01

Physiological effects of social evaluation are central in models of psychosocial influences on physical health. Experimental manipulations of evaluative threat evoke substantial cardiovascular and neuroendocrine responses in laboratory studies, but only preliminary evidence is available regarding naturally occurring evaluative threats in daily life. In such nonexperimental ambulatory studies, it is essential to distinguish effects of evaluative threat from related constructs known to alter stress, such as ability perceptions and concerns about appearance. 94 married, working couples (mean age 29.2 years) completed a 1-day (8 a.m. to 10 p.m.) ambulatory blood pressure protocol with random interval-contingent measurements using a Suntech monitor and Palm Pilot-based measures of control variables and momentary experiences of social-evaluative threat, concerns about appearance, and perceived ability. In hierarchical analyses for couples and multiple measurement occasions (Proc Mixed; SAS) and controlling individual differences (BMI, age, income) and potential confounds (e.g., posture, activity), higher reports of social-evaluative threat were associated with higher concurrent systolic (estimate = .87, SE = .34) and diastolic blood pressure (estimate = 1.06; SE = .26), both p < .02. Effects of social-evaluative threat remained significant when perceived ability and appearance concerns were controlled. Naturally occurring social-evaluative threat during daily activity is associated with increased systolic and diastolic blood pressure. Given associations between ambulatory blood pressure and risk of cardiovascular disease, the findings support conceptual models of threats to the social self as a potentially important influence on physical health.

Urinary markers of renal damage in hypertensive children diagnosed with ambulatory blood pressure monitoring.

PubMed

Girişgen, İlknur; Sönmez, Ferah; Yenisey, Ciğdem; Kurt-Omurlu, İmran

2014-01-01

Primary hypertension is the most important risk factor for chronic kidney disease in adulthood. However, the role of hypertension in kidney damage in childhood is not known exactly. The aim of this study was to evaluate the ambulatory blood pressure measurements of healthy children diagnosed as hypertensive with routine office blood pressure monitoring and to investigate the effects of primary hypertension on the kidney. Fifty-six patients who had blood pressure higher than 90th percentile during their well-child follow-up and 27 healthy children with normal blood pressure were included in the study. Twenty-four hour blood pressure measurements were recorded for all the patients. Microalbumin and N-acetyl-β-D-glucosaminidase (NAG) levels in the 24-hour urine were determined in the study groups. According to the results of ambulatory blood pressure measurements, 52% of the patients were diagnosed as white coat hypertension. The patients and the white coat hypertensive group had higher levels of urinary NAG than the control group. No significant difference was found in the levels of urinary microalbumin excretion between the primary hypertension and control groups. It was thought that ambulatory blood pressure measurement was necessary for the true diagnosis of hypertension in children, and further, that primary and white coat hypertension had effects on kidney damage in childhood. It is suggested that urine NAG excretion might be used as an early sign of hypertension-induced renal damage.

Cost-effectiveness of ambulatory blood pressure monitoring in the management of hypertension.

PubMed

Costa, Diogo; Peixoto Lima, Ricardo

2017-02-01

The prevalence of hypertension in Portugal is between 29.1% and 42.2%. International studies show that 13% of individuals have masked hypertension and 13% of diagnoses based on office blood pressure measurements are in fact white coat hypertension. More sensitive and specific blood pressure measuring methods could avoid costs associated with misdiagnosis. The aim of this study was to review the cost-effectiveness of ambulatory blood pressure monitoring (ABPM) compared to other methods in the management of hypertension. We performed a literature search in CMA Infobase, Guidelines Finder, National Guideline Clearinghouse, Bandolier, BMJ Clinical Evidence, the Cochrane Library, DARE, Medline, the Trip Database, SUMSearch and Índex das Revistas Médicas Portuguesas. We researched articles published between January 2005 and August 2015 in Portuguese, English and Spanish, using the MeSH terms "Hypertension", "Blood Pressure Monitoring, Ambulatory" and "Cost-Benefit Analysis" and the Portuguese search terms "Hipertensão", "Monitorização Ambulatorial da Pressão Arterial" and "Análise Custo-Benefício". Levels of evidence and grades of recommendation were attributed according to the Oxford Centre for Evidence-Based Medicine scale. Five hundred and twenty-five articles were identified. We included five original studies and one clinical practice guideline. All of them state that ABPM is the most cost-effective method. Two report better blood pressure control, and a Portuguese study revealed a saving of 23%. The evidence shows that ABPM is cost-effective, avoiding iatrogenic effects and reducing expenditure on treatment (grade of recommendation B). The included studies provide a solid basis, but further evidence of reproducibility is needed in research that is not based mainly on analytical models. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Household responsibilities, income, and ambulatory blood pressure among working men and women

PubMed Central

Thurston, Rebecca C.; Sherwood, Andrew; Matthews, Karen A.; Blumenthal, James A.

2011-01-01

Objective To test the hypothesis that a greater perceived responsibility for household tasks and a greater number of hours spent doing these tasks would be associated with elevated ambulatory systolic (SBP) and diastolic blood pressure (DBP). The connection between job characteristics and cardiovascular outcomes has been widely studied. However, less is known about links between household work characteristics and cardiovascular health. Methods 113 employed unmedicated hypertensive men and women underwent one day of ambulatory blood pressure (ABP) monitoring. Participants provided information on 1) the number of hours spent doing and 2) their degree of responsibility for seven household tasks (child care, pet care, caring for ill/elderly, household chores, house/car repair, yardwork, finances). Associations between task hours and responsibility ratings in relation to SBP and DBP were estimated using generalized estimating equations, with covariates age, race, gender, body mass index, location, posture. Interactions with gender and socioeconomic position were assessed. Results A greater perceived responsibility for household tasks, but not the hours spent doing these tasks, was associated with higher ambulatory SBP (b(95% confidence interval (CI))=0.93(0.29–1.56), p=0.004) and DBP (b(95%CI)=0.30(0.10–0.51), p=0.003)). Significant interactions with income indicated that associations between household responsibilities and ABP were most pronounced among low income participants (SBP: b(95%CI)=1.40(0.58–2.21), p<0.001; DBP: b(95%CI)=0.48(0.18–0.78), p<0.01). The task most strongly associated with BP was household chores. No interactions with gender were observed. Conclusions Greater perceived responsibility for household tasks was associated with elevated ABP, particularly for lower income participants. Household obligations may have important implications for cardiovascular health, meriting further empirical attention. PMID:21217097

Improving Ambulatory Saliva-Sampling Compliance in Pregnant Women: A Randomized Controlled Study

PubMed Central

Moeller, Julian; Lieb, Roselind; Meyer, Andrea H.; Loetscher, Katharina Quack; Krastel, Bettina; Meinlschmidt, Gunther

2014-01-01

Objective Noncompliance with scheduled ambulatory saliva sampling is common and has been associated with biased cortisol estimates in nonpregnant subjects. This study is the first to investigate in pregnant women strategies to improve ambulatory saliva-sampling compliance, and the association between sampling noncompliance and saliva cortisol estimates. Methods We instructed 64 pregnant women to collect eight scheduled saliva samples on two consecutive days each. Objective compliance with scheduled sampling times was assessed with a Medication Event Monitoring System and self-reported compliance with a paper-and-pencil diary. In a randomized controlled study, we estimated whether a disclosure intervention (informing women about objective compliance monitoring) and a reminder intervention (use of acoustical reminders) improved compliance. A mixed model analysis was used to estimate associations between women's objective compliance and their diurnal cortisol profiles, and between deviation from scheduled sampling and the cortisol concentration measured in the related sample. Results Self-reported compliance with a saliva-sampling protocol was 91%, and objective compliance was 70%. The disclosure intervention was associated with improved objective compliance (informed: 81%, noninformed: 60%), F(1,60)  = 17.64, p<0.001, but not the reminder intervention (reminders: 68%, without reminders: 72%), F(1,60)  = 0.78, p = 0.379. Furthermore, a woman's increased objective compliance was associated with a higher diurnal cortisol profile, F(2,64) = 8.22, p<0.001. Altered cortisol levels were observed in less objective compliant samples, F(1,705) = 7.38, p = 0.007, with delayed sampling associated with lower cortisol levels. Conclusions The results suggest that in pregnant women, objective noncompliance with scheduled ambulatory saliva sampling is common and is associated with biased cortisol estimates. To improve sampling compliance, results suggest

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. Copyright © 2016 Elsevier Inc. All rights reserved.

Sensorimotor integration of vision and proprioception for obstacle crossing in ambulatory individuals with spinal cord injury.

PubMed

Malik, Raza Naseem; Cote, Rachel; Lam, Tania

2017-01-01

Skilled walking, such as obstacle crossing, is an essential component of functional mobility. Sensorimotor integration of visual and proprioceptive inputs is important for successful obstacle crossing. The objective of this study was to understand how proprioceptive deficits affect obstacle-crossing strategies when controlling for variations in motor deficits in ambulatory individuals with spinal cord injury (SCI). Fifteen ambulatory individuals with SCI and 15 able-bodied controls were asked to step over an obstacle scaled to their motor abilities under full and obstructed vision conditions. An eye tracker was used to determine gaze behaviour and motion capture analysis was used to determine toe kinematics relative to the obstacle. Combined, bilateral hip and knee proprioceptive sense (joint position sense and movement detection sense) was assessed using the Lokomat and customized software controls. Combined, bilateral hip and knee proprioceptive sense in subjects with SCI varied and was significantly different from able-bodied subjects. Subjects with greater proprioceptive deficits stepped higher over the obstacle with their lead and trail limbs in the obstructed vision condition compared with full vision. Subjects with SCI also glanced at the obstacle more frequently and with longer fixation times compared with controls, but this was not related to proprioceptive sense. This study indicates that ambulatory individuals with SCI rely more heavily on vision to cross obstacles and show impairments in key gait parameters required for successful obstacle crossing. Our data suggest that proprioceptive deficits need to be considered in rehabilitation programs aimed at improving functional mobility in ambulatory individuals with SCI. This work is unique since it examines the contribution of combined, bilateral hip and knee proprioceptive sense on the recovery of skilled walking function, in addition to characterizing gaze behavior during a skilled walking task in people

A single-center audit of the indications and clinical impact of prolonged ambulatory small intestinal manometry.

PubMed

Ang, D; Pannemans, J; Vanuytsel, T; Tack, J

2018-05-01

Small bowel manometry is a diagnostic test available only in a few specialized referral centers. Its exact place in the management of refractory symptoms is controversial. The records of all patients who underwent 24-hour ambulatory duodenojejunal manometry over a 6-year period were retrospectively reviewed. We studied the clinical indications for small bowel manometry, and reviewed the impact of manometric findings on the clinical outcome. One hundred and forty-six studies were performed in 137 patients (46M, 91F) with a mean age of 44.9 ± 15.7 years. Mean follow-up duration was 15.1 ± 22.6 months. Appropriate endoscopic, radiological and gastric scintigraphy studies were performed in all patients prior to small bowel manometry. Criteria for abnormal motor activity were based on Bharucha's classification. The indications for small bowel manometry were chronic abdominal pain (n = 43), slow-transit constipation (n = 17), refractory gastroparesis (n = 16), chronic diarrhea (n = 7), recurrent episodes of subocclusion (n = 16), postsurgical evaluation (n = 36), suspicion of gut involvement in systemic disease (n = 9), and unexplained nausea (n = 2). The most common finding was a normal 24-hour ambulatory small bowel manometry (n = 113). Thirty-three studies yielded abnormal findings which included extrinsic neuropathy (n = 6), intrinsic neuropathy (n = 18), intestinal myopathy (n = 2), and subocclusion (n = 7). Ambulatory small bowel manometry excluded a generalized motility disorder in 77% and had a significant impact on the subsequent clinical course in 23%. Ambulatory small bowel manometry is a useful and safe diagnostic tool to complement traditional investigative modalities in patients with severe unexplained abdominal symptoms. © 2018 John Wiley & Sons Ltd.

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

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.

Obstructive sleep apnea syndrome and hypertension: ambulatory blood pressure.

PubMed

Kario, Kazuomi

2009-06-01

Obstructive sleep apnea syndrome (OSAS) is an independent risk factor for hypertension and cardiovascular disease. OSAS is the frequent underlying disease of secondary hypertension and resistant hypertension. OSAS increases both daytime and night-time ambulatory blood pressures through the activation of various neurohumoral factors including the sympathetic nervous system and the renin-angiotensin-aldosterone system. In particular, OSAS predominantly increases ambulatory BP during sleep compared with the awake period, with the result that OSAS is likely to be associated with the non-dipping pattern (diminished nocturnal BP fall) or riser pattern (higher sleep BP than awake BP) of nocturnal BP. An additional characteristic of ABP in OSAS is increased BP variability. The newly developed non-invasive hypoxia-trigger BP-monitoring system detected marked midnight BP surges (ranging from around 10 to 100 mm Hg) during sleep in OSAS patients. The exaggerated BP surge may trigger OSAS-related cardiovascular events occurring during sleep. Clinically, as nocturnal hypoxia is the determinant of morning minus evening BP difference (ME difference), OSAS should be strongly suspected when morning BP cannot be controlled <135/85 mm Hg with increased ME difference even by the specific antihypertensive medications targeting morning hypertension such as bedtime dosing of antihypertensive drugs. Understanding the characteristics of OSAS-related hypertension is essentially important to achieve perfect BP control over a 24-h period, including the sleep period, for more effective prevention of cardiovascular disease.

Prophylaxis for mucositis induced by ambulatory chemotherapy: systematic review.

PubMed

Manzi, Natália de Melo; Silveira, Renata Cristina de Campos Pereira; dos Reis, Paula Elaine Diniz

2016-04-01

The aim of this study was to perform a systematic review of clinical trials covering interventions used as prophylaxis for oral mucositis induced by ambulatory antineoplastic chemotherapy. Oral mucositis in patients undergoing chemotherapy is a side effect that can impact the quality of treatment and can interfere with eating and therapeutic adherence. Quantitative systematic review. Relevant databases were searched, from January 2002-July 2013, by using the combination of the keywords mucositis, stomatitis, neoplasms, antineoplastic agents, drug therapy, prevention and control and chemotherapy. Two researchers independently read the titles and abstracts from every cross-reference. The quality of the included studies was analysed by the Jadad Scale and the Cochrane Collaboration Risk of Bias Tool. Data were extracted from the selected studies with a data collection form developed specifically for this purpose. Of the 23 controlled clinical trials that were identified in this study, five articles evaluated the use of oral cryotherapy to prevent oral mucositis and three studies analysed the prophylactic use of glutamine. Interventions of protocols for oral care, palifermin, allopurinol and chlorhexidine were evaluated by two articles each. Interventions of zinc sulphate, amifostine, chewing gum, sucralfate, recombination human intestinal trefoil factor, kefir and vitamin E were evaluated by one article each. There is strong evidence that cryotherapy can prevent oral mucositis arising from ambulatory treatment with 5-flurouracil chemotherapy. Other interventions, although showing positive results in preventing oral mucositis, require further study to confirm their conclusions. © 2015 John Wiley & Sons Ltd.

Adjuvant Agents in Regional Anesthesia in the Ambulatory Setting.

PubMed

Koyyalamudi, Veerandra; Sen, Sudipta; Patil, Shilpadevi; Creel, Justin B; Cornett, Elyse M; Fox, Charles J; Kaye, Alan D

2017-01-01

A majority of surgical practice has involved ambulatory centers with the number of outpatient operations in the USA doubling to 26.8 million per year. Local anesthesia delivery provides numerous benefits, including increased satisfaction, earlier discharge, and reduction in unplanned hospital admission. Further, with the epidemic of opioid mediated overdoses, local anesthesia can be a key tool in providing an opportunity to reduce the need for other analgesics postoperatively. Adjuvants such as epinephrine and clonidine enhance local anesthetic clinical utility. Further, dexmedetomidine prolongs regional blockade duration effects. There has also been a significant interest recently in the use of dexamethasone. Studies have demonstrated a significant prolongation in motor and sensory block with perineural dexamethasone. Findings are conflicting as to whether intravenous dexamethasone has similar beneficial effects. However, considering the possible neurotoxicity effects, which perineural dexamethasone may present, it would be prudent not to consider intravenously administered dexamethasone to prolong regional block duration. Many studies have also demonstrated neurotoxicity from intrathecally administered midazolam. Therefore, midazolam as an adjuvant is not recommended. Magnesium prolongs regional block duration but related to paucity of studies as of yet, cannot be recommended. Tramadol yields inconsistent results and ketamine is associated with psychotomimetic adverse effects. Buprenorphine consistently increases regional block duration and reduce opioid requirements by a significant amount. Future studies are warranted to define best practice strategies for these adjuvant agents. The present review focuses on the many roles of local anesthetics in current ambulatory practice.

Physician-based transactions: the sale of medical practices, ambulatory surgery centers, and dialysis facilities.

PubMed

Becker, S; Pristave, R J

1995-01-01

This article provides an overview of the critical business and legal issues encountered in sales of practices, ambulatory surgery centers, and dialysis facilities. Specifically, it discusses prototypical valuations, transaction structures, and the principal legal issues that must be addressed.

Cost analysis of percutaneous fixation of hand fractures in the main operating room versus the ambulatory setting.

PubMed

Gillis, Joshua A; Williams, Jason G

2017-08-01

To date, there have been no studies identifying the cost differential for performing closed reduction internal fixation (CRIF) of hand fractures in the operating room (OR) versus an ambulatory setting. Our goal was to analyse the cost and efficiency of performing CRIF in these two settings and to investigate current practice trends in Canada. A detailed analysis of the costs involved both directly and indirectly in the CRIF of a hand fracture was conducted. Hospital records were used to calculate efficiency. A survey was distributed to practicing plastic surgeons across Canada regarding their current practice of managing hand fractures. In an eight-hour surgical block we are able to perform five CRIF in the OR versus eight in an ambulatory setting. The costs of performing a CRIF in the OR under local anaesthetic, not including surgeon compensation, is $461.27 Canadian (CAD) compared to $115.59 CAD in the ambulatory setting, a 299% increase. The use of a regional block increases the cost to $665.49 CAD, a 476% increase. The main barrier to performing CRIFs in an outpatient setting is the absence of equipment necessary to perform these cases effectively, based on survey results. The use of the OR for CRIF of hand fractures is associated with a significant increase in cost and hospital resources with decreased efficiency. For appropriately selected hand fractures, CRIF in an ambulatory setting is less costly and more efficient compared to the OR and resources should be allocated to facilitate CRIF in this setting. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

International accreditation of ambulatory surgical centers and medical tourism.

PubMed

McGuire, Michael F

2013-07-01

The two forces that have driven the increase in accreditation of outpatient ambulatory surgery centers (ASC's) in the United States are reimbursement of facility fees by Medicare and commercial insurance companies, which requires either accreditation, Medicare certification, or state licensure, and state laws which mandate one of these three options. Accreditation of ASC's internationally has been driven by national requirements and by the competitive forces of "medical tourism." The three American accrediting organizations have all developed international programs to meet this increasing demand outside of the United States. Copyright © 2013. Published by Elsevier Inc.

Ambulatory Seizure Monitoring: From Concept to Prototype Device.

PubMed

Myers, Mark H; Threatt, Madeline; Solies, Karsten M; McFerrin, Brent M; Hopf, Lindsey B; Birdwell, J Douglas; Sillay, Karl A

2016-07-01

The brain, made up of billions of neurons and synapses, is the marvelous core of human thought, action and memory. However, if neuronal activity manifests into abnormal electrical activity across the brain, neural behavior may exhibit synchronous neural firings known as seizures. If unprovoked seizures occur repeatedly, a patient may be diagnosed with epilepsy. The scope of this project is to develop an ambulatory seizure monitoring system that can be used away from a hospital, making it possible for the user to stay at home, and primary care personnel to monitor a patient's seizure activity in order to provide deeper analysis of the patient's condition and apply personalized intervention techniques. The ambulatory seizure monitoring device is a research device that has been developed with the objective of acquiring a portable, clean electroencephalography (EEG) signal and transmitting it wirelessly to a handheld device for processing and notification. This device is comprised of 4 phases: acquisition, transmission, processing and notification. During the acquisition stage, the EEG signal is detected using EEG electrodes; these signals are filtered and amplified before being transmitted in the second stage. The processing stage encompasses the signal processing and seizure prediction. A notification is sent to the patient and designated contacts, given an impending seizure. Each of these phases is comprised of various design components, hardware and software. The experimental findings illustrate that there may be a triggering mechanism through the phase lock value method that enables seizure prediction. The device addresses the need for long-term monitoring of the patient's seizure condition in order to provide the clinician a better understanding of the seizure's duration and frequency and ultimately provide the best remedy for the patient.

Management competencies required in ambulatory care settings.

PubMed

Brooke, P P; Hudak, R P; Finstuen, K; Trounson, J

1998-01-01

A study was conducted to identify the most important competencies physician executives in medical groups and other ambulatory settings will need to have in the next five years. The specific job skills, knowledge, and abilities (SKA) that physician executives will need to acquire these competencies were also explored. The Delphi techniques were used to analyze responses from two surveys from members of the American College of Medical Practice Executives. The most important competencies were grouped into 13 management domains, each with specific SKAs. "Managing health care resources to create quality and value" and "fundamentals of business and finance" were rated as the most important competencies. The most frequently rated SKA was the "ability to build and maintain credibility and trust."

Blind source separation for ambulatory sleep recording

PubMed Central

Porée, Fabienne; Kachenoura, Amar; Gauvrit, Hervé; Morvan, Catherine; Carrault, Guy; Senhadji, Lotfi

2006-01-01

This paper deals with the conception of a new system for sleep staging in ambulatory conditions. Sleep recording is performed by means of five electrodes: two temporal, two frontal and a reference. This configuration enables to avoid the chin area to enhance the quality of the muscular signal and the hair region for patient convenience. The EEG, EMG and EOG signals are separated using the Independent Component Analysis approach. The system is compared to a standard sleep analysis system using polysomnographic recordings of 14 patients. The overall concordance of 67.2% is achieved between the two systems. Based on the validation results and the computational efficiency we recommend the clinical use of the proposed system in a commercial sleep analysis platform. PMID:16617618

Processing loaner instruments in an ambulatory surgery center.

PubMed

Huter-Kunish, Gloria G

2009-05-01

Loaner instruments often do not arrive at receiving facilities in the time frame or the condition that is needed to use them safely. Their cleaning and decontamination status may be unknown. There may be no inventory of what has been loaned or information about processing requirements for the instrument's use. These situations can create problems for both the loaning facility and the receiving facility and must be addressed to reduce costs from damage to or loss of instruments.The use of documents and checklists to verify the cleaning,decontamination, and sterilization processes used allows ambulatory surgery centers to solve these problems,cut costs, and protect staff members and patients.

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

PubMed

Benyamina, A; Reynaud, M

2016-02-01

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

Predictors of unanticipated admission following ambulatory surgery: a retrospective case-control study.

PubMed

Whippey, Amanda; Kostandoff, Greg; Paul, James; Ma, Jinhui; Thabane, Lehana; Ma, Heung Kan

2013-07-01

The primary objectives of this historical case-control study were to evaluate the incidence of and reasons and risk factors for adult unanticipated admissions in three tertiary care Canadian hospitals following ambulatory surgery. A random sample of 200 patients requiring admission (cases) and 200 patients not requiring admission (controls) was taken from 20,657 ambulatory procedures was identified and compared. The following variables were included: demographics, reason for admission, type of anesthesia, surgical procedure, length of procedure, American Society of Anesthesiologists' (ASA) classification, surgical completion time, pre-anesthesia clinic, medical history, medications (classes), and perioperative complications. Multiple logistic regression analysis was used to assess factors associated with unanticipated admissions. The incidence of unanticipated admission following ambulatory surgery was 2.67%. The most common reasons for admission were surgical (40%), anesthetic (20%), and medical (19%). The following factors were found to be associated with an increased risk of unanticipated admission: length of surgery of one to three hours (odds ratio [OR] 16.70; 95% confidence interval [CI] 4.10 to 67.99) and length of surgery more than three hours (OR 4.26; 95% CI 2.40 to 7.55); ASA class III (OR 4.60; 95% CI 1.81 to 11.68); ASA class IV (OR 6.51; 95% CI 1.66 to 25.59); advanced age (> 80 yr) (OR 5.41; 95% CI 1.54 to 19.01); and body mass index (BMI) of 30-35 (OR 2.81; 95% CI 1.31 to 6.04). Current smoking status was found to be associated with a decreased likelihood of unanticipated admission (OR 0.44; 95% CI 0.23 to 0.83), as was monitored anesthesia care when compared with general anesthesia (OR 0.17; 95% CI 0.04 to 0.68) and plastic (OR 0.18; 95% CI 0.07 to 0.50), orthopedic (OR 0.16; 95% CI 0.08 to 0.33), and dental/ear-nose-throat surgery (OR 0.32; 95% CI 0.13 to 0.83) when compared with general surgery. Other comorbid conditions did not impact

The Comprehensive Care Project: Measuring Physician Performance in Ambulatory Practice

PubMed Central

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

2010-01-01

Objective To investigate the feasibility, reliability, and validity of comprehensively assessing physician-level performance in ambulatory practice. Data Sources/Study Setting Ambulatory-based general internists in 13 states participated in the assessment. Study Design We assessed physician-level performance, adjusted for patient factors, on 46 individual measures, an overall composite measure, and composite measures for chronic, acute, and preventive care. Between- versus within-physician variation was quantified by intraclass correlation coefficients (ICC). External validity was assessed by correlating performance on a certification exam. Data Collection/Extraction Methods Medical records for 236 physicians were audited for seven chronic and four acute care conditions, and six age- and gender-appropriate preventive services. Principal Findings Performance on the individual and composite measures varied substantially within (range 5–86 percent compliance on 46 measures) and between physicians (ICC range 0.12–0.88). Reliabilities for the composite measures were robust: 0.88 for chronic care and 0.87 for preventive services. Higher certification exam scores were associated with better performance on the overall (r = 0.19; p <.01), chronic care (r = 0.14, p = .04), and preventive services composites (r = 0.17, p = .01). Conclusions Our results suggest that reliable and valid comprehensive assessment of the quality of chronic and preventive care can be achieved by creating composite measures and by sampling feasible numbers of patients for each condition. PMID:20819110

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

PubMed

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

2010-12-01

To investigate the feasibility, reliability, and validity of comprehensively assessing physician-level performance in ambulatory practice. Ambulatory-based general internists in 13 states participated in the assessment. We assessed physician-level performance, adjusted for patient factors, on 46 individual measures, an overall composite measure, and composite measures for chronic, acute, and preventive care. Between- versus within-physician variation was quantified by intraclass correlation coefficients (ICC). External validity was assessed by correlating performance on a certification exam. Medical records for 236 physicians were audited for seven chronic and four acute care conditions, and six age- and gender-appropriate preventive services. Performance on the individual and composite measures varied substantially within (range 5-86 percent compliance on 46 measures) and between physicians (ICC range 0.12-0.88). Reliabilities for the composite measures were robust: 0.88 for chronic care and 0.87 for preventive services. Higher certification exam scores were associated with better performance on the overall (r = 0.19; p<.01), chronic care (r = 0.14, p = .04), and preventive services composites (r = 0.17, p = .01). Our results suggest that reliable and valid comprehensive assessment of the quality of chronic and preventive care can be achieved by creating composite measures and by sampling feasible numbers of patients for each condition. © Health Research and Educational Trust.

Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions.

PubMed

Davis, Matthew A; Onega, Tracy; Weeks, William B; Lurie, Jon D

2012-09-01

Serial, cross-sectional, nationally representative surveys of noninstitutionalized US adults. To examine expenditures on common ambulatory health services for the management of back and neck conditions. Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population. We used the Medical Expenditure Panel Survey to examine adult (aged 18 yr or older) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions. Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. During the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; although physical therapy was the most costly service overall, in recent years those costs have contracted. Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions.

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

PubMed

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

2016-03-01

This study analyzes hospitalizations due to ambulatory care-sensitive conditions with a focus on infectious and parasitic diseases (IPDs) and validates the Hospital Information System, Brazilian Unified National Health System (SIH/SUS) for recording hospitalizations due to ambulatory care-sensitive conditions in a hospital in the Federal District, Brazil, in 2012. The study estimates the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the SIH for recording hospitalizations due to ambulatory care-sensitive conditions, with the patient's medical file as the gold standard. There were 1,604 hospitalizations for hospitalizations due to ambulatory care-sensitive conditions (19.6%, 95%CI: 18.7-20.5), and the leading IPDs were renal and urinary tract infection, infection of the skin and subcutaneous tissue, and infectious gastroenteritis. IPDs were the leading cause of hospitalization in the 20 to 29-year age bracket and caused 28 deaths. Sensitivity was 70.1% (95%CI: 60.5-79.7), specificity 88.4% (95%CI: 85.6-91.2), PPV = 51.7% (95%CI: 42.7-60.7), and NPV = 94.3% (95%CI: 92.2-96.4). The findings for admissions due to ACSCs in this hospital were similar to those of other studies, featuring admissions for IPDs. The SIH/SUS database was more specific than sensitive.

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.

Review of systems, physical examination, and routine tests for case-finding in ambulatory patients.

PubMed

Boland, B J; Wollan, P C; Silverstein, M D

1995-04-01

The screening value of the comprehensive review of systems and the complete physical examination in detecting unsuspected diseases for which therapeutic interventions are initiated has not been formally studied in ambulatory patients. The medical records of 100 randomly selected adult patients who had an ambulatory general medical evaluation at the Mayo Clinic in 1990-1991 were surveyed to compare review of systems and physical examination with routine laboratory tests, chest radiography, and electrocardiography as case-finding maneuvers. The main outcome measure was the therapeutic yield of each case-finding maneuver, defined as the proportion of maneuvers leading to a new therapy for a new clinically important diagnosis. The utilization rate of routine tests in the 100 patients (mean age: 59 +/- 16 years; 58% women) was high, ranging from 77 to 98%. Overall, the case-finding maneuvers led to 36 unsuspected clinically important diagnoses and resulted in 25 new therapeutic interventions. Higher therapeutic yield was observed for review of systems (7%), physical examination (5%), and lipid screening (9.2%) than for chemistry group (2.2%), complete blood count (1.8%), thyroid tests (1.5%), urinalysis (1.1%), electrocardiography (0%), or chest radiography (0%). The number of therapeutic interventions was not associated with patient's age (P = 0.55), sex (P = 0.88), comorbidity (P = 0.30) or with the time interval since the last general medical evaluation (P = 0.12). Based on therapeutic yield, these data suggest that review of systems and physical examination are valuable case-finding maneuvers in the periodic medical evaluation of ambulatory patients.

The effect of race on postsurgical ambulatory medical follow-up among United States Veterans.

PubMed

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

2017-08-01

To investigate the association between self-identified black or African American race and the presence of ambulatory internal medicine follow-up in the year after surgery. Our hypothesis was that among US Veterans who presented for surgery, black or African American race would be associated with a decreased likelihood to receive ambulatory internal medicine follow-up in the year after surgery. Retrospective observational. All US Veterans Affairs hospitals. A total of 236,200 Veterans undergoing surgery between 2006 and 2011 who were discharged within 10 days of surgery and survived the full 1-year exposure period. None. Attendance at an internal medicine follow-up appointment within 1 year after surgery. After controlling for year of surgery, age, age ≥65 years, sex, Hispanic ethnicity, and number of inpatient days, black or African American patients were 11% more likely to lack internal medicine follow-up after surgery (adjusted odds ratio, 1.11; 95% confidence interval, 1.06-1.16). When accounting for geographic region, this difference remained significant at the Bonferoni-corrected P < .007 level only in the Midwest United States where black or African American patients were 28% more likely to lack medical follow-up in the year after surgery (odds ratio, 1.28; 95% confidence interval, 1.16-1.42; P < .0001). The disparity in ambulatory medical follow-up following surgery among black or African American vs nonblack or non-African American Veterans in the Midwest region deserves further study and may lead to important quality improvement initiatives aimed specifically at this population. Copyright © 2016 Elsevier Inc. All rights reserved.

Ambulatory rehabilitation in multiple sclerosis.

PubMed

Kelleher, Kevin John; Spence, William; Solomonidis, Stephan; Apatsidis, Dimitrios

2009-01-01

Multiple sclerosis (MS) is an autoimmunogenic disease involving demyelination within the central nervous system. Many of the typical impairments associated with MS can affect gait patterns. With walking ability being one of the most decisive factors when assessing quality of life and independent living, this review focuses on matters, which are considered of significance for maintaining and supporting ambulation. This article is an attempt to describe current research and available interventions that the caring healthcare professional can avail of and to review the present trends in research to further these available options. Evidence-based rehabilitation techniques are of interest in the care of patients with MS, given the various existing modalities of treatment. In this review, we summarise the primary factors affecting ambulation and highlight available treatment methods. We review studies that have attempted to characterise gait deficits within this patient population. Finally, as ambulatory rehabilitation requires multidisciplinary interventions, we examine approaches, which may serve to support and maintain ambulation within this patient group for as long as possible.

Curvularia lunata, a rare fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD); a rare case report.

PubMed

Subramanyam, Haritha; Elumalai, Ramprasad; Kindo, Anupma Jyoti; Periasamy, Soundararajan

2016-01-01

Peritonitis is an inflammation of the peritoneum that occurs in patients with end-stage renal disease (ESRD) treated by peritoneal dialysis. Fungal peritonitis is a dreaded complication of peritoneal dialysis. Curvularia lunata is known to cause extra renal disease like endocarditis, secondary allergic bronchopulmonary aspergillosis and endophthalmitis. This case report presents a case of continuous ambulatory peritoneal dialysis peritonitis with this disease and its management. This case is of a 45-year-old man, presented with ESRD, secondary to diabetic nephropathy. After 3 months of hemodialysis the patient was put on continuous ambulatory peritoneal dialysis (CAPD). Local Examination at catheter site showed skin excoriation and purulent discharge. Further peritoneal dialysis (PD) fluid analysis showed neutrophilic leukocytosis and diagnosis of Curvularia lunata PD peritonitis.

Change in Ambulatory Ability of Adolescents and Young Adults with Cerebral Palsy

ERIC Educational Resources Information Center

Day, Steven M.; Wu, Yvonne W.; Strauss, David J.; Shavelle, Robert M.; Reynolds, Robert J.

2007-01-01

This study aimed to determine the probability that a child with cerebral palsy (CP) will lose or gain ambulatory ability through adolescence and young adulthood. We analyzed retrospectively data from 1987 to 2002 on Californians with CP initially aged 10 years (SD 0.9y; n=7550 [4304 males, 3246 females]) and 25 years (SD 0.8y; n=5721 [3261 males,…

The effect of depression on sleep quality and the circadian rhythm of ambulatory blood pressure in older patients with hypertension.

PubMed

Ma, Lina; Li, Yun

2017-05-01

To explore the effect of depression on the sleep quality, and the circadian rhythm of ambulatory blood pressure in patients with essential hypertension. A total of 73 older patients with hypertension were screened for depression and divided into two groups. The Pittsburgh Sleep Quality Index (PSQI) and the circadian rhythm of ambulatory blood pressure were compared between the non-depressed (control) and depressed (case) group. In the case group, 24h ambulatory SBP and DBP, and nocturnal SBP and DBP were higher than in the control group, and the circadian rhythm of non-dipper was higher (67.22% vs 40.13%，P<0.01). There was a positive correlation between PSQI and depression (r=0.432, P<0.01). There was a significant correlation between sleep quality and depression in older patients with hypertension. Depression increases the circadian rhythm of non-dipper in older patients with hypertension. Copyright © 2017 Elsevier Ltd. All rights reserved.

Ambulatory (24 h) blood pressure and arterial stiffness measurement in Marfan syndrome patients: a case control feasibility and pilot study.

PubMed

Hillebrand, Matthias; Nouri, Ghazaleh; Hametner, Bernhard; Parragh, Stephanie; Köster, Jelena; Mortensen, Kai; Schwarz, Achim; von Kodolitsch, Yskert; Wassertheurer, Siegfried

2016-05-06

The aim of this work is the investigation of measures of ambulatory brachial and aortic blood pressure and indices of arterial stiffness and aortic wave reflection in Marfan patients. A case-control study was conducted including patients with diagnosed Marfan syndrome following Ghent2 nosology and healthy controls matched for sex, age and daytime brachial systolic blood pressure. For each subject a 24 h ambulatory blood pressure and 24 h pulse wave analysis measurement was performed. All parameters showed a circadian pattern whereby pressure dipping was more pronounced in Marfan patients. During daytime only Marfan patients with aortic root surgery showed increased pulse wave velocity. In contrast, various nighttime measurements, wave reflection determinants and circadian patterns showed a significant difference. The findings of our study provide evidence that ambulatory measurement of arterial stiffness parameters is feasible and that these determinants are significantly different in Marfan syndrome patients compared to controls in particular at nighttime. Further investigation is therefore indicated.

Efficacy of Keyhole Approach to Carpal Tunnel Syndrome under Ambulatory Strategy

PubMed Central

García-Mercado, César J.; Segura-Durán, Iván; Zepeda-Gutiérrez, Luis A.

2017-01-01

The carpal tunnel syndrome is one of the most common entrapment neuropathies found in humans. Currently, the gold standard is surgical treatment using different modalities. The minimally invasive strategy with high resolution capacity and less morbidity is still a challenge. Methods. Prospective nonrandomised clinical trial in which a minimally invasive microsurgical approach was used following the keyhole principle in 55 consecutive patients and 65 hands under local anesthesia and ambulatory strategy. They were evaluated with stringent inclusion criteria with the Levine severity and functional status scale and with a 2-year follow-up. Results. 90% showed immediate improvement dropping to grades 1-2 in all items of the scale referring to pain and numbness. 97% reported improvement, as of the first month, and 3% reported persistence of symptoms, although at a lesser degree and with no functional limitation. No incidents were identified during the procedure and 98% of patients were discharged within an hour after the surgical procedure. Conclusions. The microsurgical approach described following the keyhole principle is a treatment option that, under local anesthesia and ambulatory management, may represent an alternative strategy of an effective treatment reducing the morbidity. This trial is registered with Clinical Trials Protocol Identifier NCT03062722. PMID:28484650

Ambulatory activity classification with dendogram-based support vector machine: Application in lower-limb active exoskeleton.

PubMed

Mazumder, Oishee; Kundu, Ananda Sankar; Lenka, Prasanna Kumar; Bhaumik, Subhasis

2016-10-01

Ambulatory activity classification is an active area of research for controlling and monitoring state initiation, termination, and transition in mobility assistive devices such as lower-limb exoskeletons. State transition of lower-limb exoskeletons reported thus far are achieved mostly through the use of manual switches or state machine-based logic. In this paper, we propose a postural activity classifier using a 'dendogram-based support vector machine' (DSVM) which can be used to control a lower-limb exoskeleton. A pressure sensor-based wearable insole and two six-axis inertial measurement units (IMU) have been used for recognising two static and seven dynamic postural activities: sit, stand, and sit-to-stand, stand-to-sit, level walk, fast walk, slope walk, stair ascent and stair descent. Most of the ambulatory activities are periodic in nature and have unique patterns of response. The proposed classification algorithm involves the recognition of activity patterns on the basis of the periodic shape of trajectories. Polynomial coefficients extracted from the hip angle trajectory and the centre-of-pressure (CoP) trajectory during an activity cycle are used as features to classify dynamic activities. The novelty of this paper lies in finding suitable instrumentation, developing post-processing techniques, and selecting shape-based features for ambulatory activity classification. The proposed activity classifier is used to identify the activity states of a lower-limb exoskeleton. The DSVM classifier algorithm achieved an overall classification accuracy of 95.2%. Copyright © 2016 Elsevier B.V. All rights reserved.

Estimating Treatment and Treatment Times for Special and Nonspecial Patients in Hospital Ambulatory Dental Clinics.

ERIC Educational Resources Information Center

Rosenberg, Dara J.; And Others

1986-01-01

A study compared the treatments and the amount of time needed for treatment of the dental needs of developmentally disabled, severely compromised, and moderately compromised patients with those of nondisabled patients in a hospital ambulatory dental clinic. (MSE)

Infection prevention and control in pediatric ambulatory settings.

PubMed

2007-09-01

Since the American Academy of Pediatrics published a statement titled "Infection Control in Physicians' Offices" (Pediatrics. 2000;105[6]:1361-1369), there have been significant changes that prompted this updated statement. Infection prevention and control is an integral part of pediatric practice in ambulatory medical settings as well as in hospitals. Infection prevention and control practices should begin at the time the ambulatory visit is scheduled. All health care personnel should be educated regarding the routes of transmission and techniques used to prevent transmission of infectious agents. Policies for infection prevention and control should be written, readily available, updated annually, and enforced. The standard precautions for hospitalized patients from the Centers for Disease Control and Prevention, with a modification from the American Academy of Pediatrics exempting the use of gloves for routine diaper changes and wiping a well child's nose or tears, are appropriate for most patient encounters. As employers, pediatricians are required by the Occupational Safety and Health Administration to take precautions to identify and protect employees who are likely to be exposed to blood or other potentially infectious materials while on the job. Key principles of standard precautions include hand hygiene (ie, use of alcohol-based hand rub or hand-washing with soap [plain or antimicrobial] and water) before and after every patient contact; implementation of respiratory hygiene and cough-etiquette strategies for patients with suspected influenza or infection with another respiratory tract pathogen to the extent feasible; separation of infected, contagious children from uninfected children when feasible; safe handling and disposal of needles and other sharp medical devices and evaluation and implementation of needle-safety devices; appropriate use of personal protective equipment such as gloves, gowns, masks, and eye protection; and appropriate sterilization

Ambulatory Seizure Monitoring: From Concept to Prototype Device

PubMed Central

Myers, Mark H.; Threatt, Madeline; Solies, Karsten M.; McFerrin, Brent M.; Hopf, Lindsey B.; Birdwell, J. Douglas; Sillay, Karl A.

2016-01-01

Background The brain, made up of billions of neurons and synapses, is the marvelous core of human thought, action and memory. However, if neuronal activity manifests into abnormal electrical activity across the brain, neural behavior may exhibit synchronous neural firings known as seizures. If unprovoked seizures occur repeatedly, a patient may be diagnosed with epilepsy. Purpose The scope of this project is to develop an ambulatory seizure monitoring system that can be used away from a hospital, making it possible for the user to stay at home, and primary care personnel to monitor a patient's seizure activity in order to provide deeper analysis of the patient's condition and apply personalized intervention techniques. Methods The ambulatory seizure monitoring device is a research device that has been developed with the objective of acquiring a portable, clean electroencephalography (EEG) signal and transmitting it wirelessly to a handheld device for processing and notification. Result This device is comprised of 4 phases: acquisition, transmission, processing and notification. During the acquisition stage, the EEG signal is detected using EEG electrodes; these signals are filtered and amplified before being transmitted in the second stage. The processing stage encompasses the signal processing and seizure prediction. A notification is sent to the patient and designated contacts, given an impending seizure. Each of these phases is comprised of various design components, hardware and software. The experimental findings illustrate that there may be a triggering mechanism through the phase lock value method that enables seizure prediction. Conclusion The device addresses the need for long-term monitoring of the patient's seizure condition in order to provide the clinician a better understanding of the seizure's duration and frequency and ultimately provide the best remedy for the patient. PMID:27647960

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

PubMed

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

2017-09-01

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

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.

Pro: Ambulatory blood pressure should be used in all patients on hemodialysis

PubMed Central

Agarwal, Rajiv

2015-01-01

In the adult population in general and among people with chronic kidney disease in particular, it is now well established that hypertension is a major driver of renal disease progression and cardiovascular morbidity and mortality [1–4]. Although the contribution of hypertension to cardiovascular morbidity and mortality among patients on long-term dialysis continues to be debated [5–8], a major barrier to detect hypertension as a risk factor for cardiovascular events in these patients has been the inability to diagnose hypertension [9]. Largely to blame has been the easy availability of pre-dialysis and post-dialysis blood pressure recordings in stark contrast to ambulatory blood pressure measurements in dialysis patients to accurately diagnose the presence or control of hypertension [10]. It is increasingly becoming clear that out-of-office blood pressure recordings are superior to clinic recordings in making a diagnosis, assessing target organ damage, evaluating prognosis and managing patients with hypertension [11–15]. In this debate, I have been asked to defend the position that ambulatory blood pressure recordings should be systematically applied to all patients on hemodialysis. PMID:26022728

Automated measurement of office, home and ambulatory blood pressure in atrial fibrillation.

PubMed

Kollias, Anastasios; Stergiou, George S

2014-01-01

1. Hypertension and atrial fibrillation (AF) often coexist and are strong risk factors for stroke. Current guidelines for blood pressure (BP) measurement in AF recommend repeated measurements using the auscultatory method, whereas the accuracy of the automated devices is regarded as questionable. This review presents the current evidence on the feasibility and accuracy of automated BP measurement in the presence of AF and the potential for automated detection of undiagnosed AF during such measurements. 2. Studies evaluating the use of automated BP monitors in AF are limited and have significant heterogeneity in methodology and protocols. Overall, the oscillometric method is feasible for static (office or home) and ambulatory use and appears to be more accurate for systolic than diastolic BP measurement. 3. Given that systolic hypertension is particularly common and important in the elderly, the automated BP measurement method may be acceptable for self-home and ambulatory monitoring, but not for professional office or clinic measurement. 4. An embedded algorithm for the detection of asymptomatic AF during routine automated BP measurement with high diagnostic accuracy has been developed and appears to be a useful screening tool for elderly hypertensives. © 2013 Wiley Publishing Asia Pty Ltd.

Facilitating Ambulatory Electronic Health Record System Implementation: Evidence from a Qualitative Study

PubMed Central

Hefner, Jennifer; Robbins, Julie; Huerta, Timothy R.

2013-01-01

Background. Ambulatory care practices have increasing interest in leveraging the capabilities of electronic health record (EHR) systems, but little information is available documenting how organizations have successfully implemented these systems. Objective. To characterize elements of successful electronic health record (EHR) system implementation and to synthesize the key informants' perspectives about successful implementation practices. Methods. Key informant interviews and focus groups were conducted with a purposive sample of individuals from US healthcare organizations identified for their success with ambulatory EHR implementation. Rigorous qualitative data analyses used both deductive and inductive methods. Results. Participants identified personal and system-related barriers, at both the individual and organization levels, including poor computer skills, productivity losses, resistance to change, and EHR system failure. Implementation success was reportedly facilitated by careful planning and consistent communication throughout distinct stages of the implementation process. A significant element of successful implementation was an emphasis on optimization, both during “go-live” and, subsequently, when users had more experience with the system. Conclusion. Successful EHR implementation requires both detailed planning and clear mechanisms to deal with unforeseen or unintended consequences. Focusing on user buy-in early and including plans for optimization can facilitate greater success. PMID:24228257

Peritonitis Due to Roseomonas fauriae in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis

PubMed Central

Bibashi, Evangelia; Sofianou, Danai; Kontopoulou, Konstantina; Mitsopoulos, Efstathios; Kokolina, Elisabeth

2000-01-01

Roseomonas is a newly described genus of pink-pigmented, nonfermentative, gram-negative bacteria that have been recognized as a cause of human infections. Roseomonas fauriae is a species rarely isolated from clinical specimens. We report the first known case of peritonitis caused by R. fauriae in a patient receiving continuous ambulatory peritoneal dialysis. PMID:10618142

Where the United States Spends its Spine Dollars: Expenditures on different ambulatory services for the management of back and neck conditions

PubMed Central

Davis, Matthew A.

2012-01-01

Study Design Serial, cross-sectional, nationally representative surveys of non-institutionalized adults. Objective To examine expenditures on common ambulatory health services for the management of back and neck conditions. Summary of Background Data Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population. Methods We used the Medical Expenditure Panel Survey (MEPS) to examine adult (age ≥ 18 years) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions. Results Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. Over the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; while physical therapy was the most costly service overall, in recent years those costs have contracted. Conclusion Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions. PMID:22433497

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

PubMed

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

2018-04-01

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

Coping with a life event in bipolar disorder: ambulatory measurement, signalling and early treatment.

PubMed

Knapen, Stefan E; Riemersma-van der Lek, Rixt F; Haarman, Bartholomeus C M; Schoevers, Robert A

2016-10-13

Disruption of the biological rhythm in patients with bipolar disorder is a known risk factor for a switch in mood. This case study describes how modern techniques using ambulatory assessment of sleep parameters can help in signalling a mood switch and start early treatment. We studied a 40-year-old woman with bipolar disorder experiencing a life event while wearing an actigraph to measure sleep-wake parameters. The night after the life event the woman had sleep later and shorter sleep duration. Adequate response of both the woman and the treating psychiatrist resulted in two normal nights with the use of 1 mg lorazepam, possibly preventing further mood disturbances. Ambulatory assessment of the biological rhythm can function as an add-on to regular signalling plans for prevention of episodes in patients with bipolar disorder. More research should be conducted to validate clinical applicability, proper protocols and to understand underlying mechanisms. 2016 BMJ Publishing Group Ltd.

Exposure to Racial Discrimination and Ambulatory Blood Pressure in Women with Type 2 Diabetes.

PubMed

Wagner, Julie; Tennen, Howard; Finan, Patrick; Feinn, Richard; Burg, Matthew M; Seawell, Asani; White, William B

2016-10-01

Diabetes is the only disorder in which women's risk for heart disease exceeds men's. Elevated blood pressure (BP) increases cardiovascular risk in people with type 2 diabetes. Racial discrimination and neuroticism are both associated with BP levels but have not been examined in concert. This study investigated self-reported racial discrimination, neuroticism and ambulatory BP in women with type 2 diabetes. Thirty-nine Black and 38 White women completed a race-neutral version of the Schedule of Racist Events; BP was evaluated using ambulatory monitoring devices. Actigraphy and diaries were used to document times of sleep and wakefulness. Racial discrimination interacted with neuroticism to predict systolic and diastolic BP both while awake and during sleep, after adjustment for covariates. For each, the influence of racist events was stronger at lower levels of neuroticism. Racial discrimination is associated with higher levels of 24-h BP in diabetic women who are low in neuroticism. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Ambulatory Voice Biofeedback: Relative Frequency and Summary Feedback Effects on Performance and Retention of Reduced Vocal Intensity in the Daily Lives of Participants with Normal Voices

ERIC Educational Resources Information Center

Van Stan, Jarrad H.; Mehta, Daryush D.; Sternad, Dagmar; Petit, Robert; Hillman, Robert E.

2017-01-01

Purpose: Ambulatory voice biofeedback has the potential to significantly improve voice therapy effectiveness by targeting carryover of desired behaviors outside the therapy session (i.e., retention). This study applies motor learning concepts (reduced frequency and delayed, summary feedback) that demonstrate increased retention to ambulatory voice…

A comparison study of brachial blood pressure recorded with Spacelabs 90217A and Mobil-O-Graph NG devices under static and ambulatory conditions.

PubMed

Sarafidis, P A; Lazaridis, A A; Imprialos, K P; Georgianos, P I; Avranas, K A; Protogerou, A D; Doumas, M N; Athyros, V G; Karagiannis, A I

2016-12-01

Ambulatory blood pressure monitoring is an important tool in hypertension diagnosis and management. Although several ambulatory devices exist, comparative studies are scarce. This study aimed to compare for the first time brachial blood pressure levels of Spacelabs 90217A and Mobil-O-Graph NG, under static and ambulatory conditions. We examined 40 healthy individuals under static (study A) and ambulatory (study B) conditions. In study A, participants were randomized into two groups that included blood pressure measurements with mercury sphygmomanometer, Spacelabs and Mobil-O-Graph devices with reverse order of recordings. In study B, simultaneous 6-h recordings with both devices were performed with participants randomized in two sequences of device positioning with arm reversal at 3 h. Finally, all the participants filled in a questionnaire rating their overall preference for a device. In study A, brachial systolic blood pressure (117.2±10.3 vs 117.1±9.8 mm Hg, P=0.943) and diastolic blood pressure (73.3±9.4 mm Hg vs 74.1±9.4 mm Hg, P=0.611) did not differ between Spacelabs and Mobil-O-Graph or vs sphygmomanometer (117.8±11.1 mm Hg, P=0.791 vs Spacelabs, P=0.753 vs Mobil-O-Graph). Similarly, no differences were found in ambulatory systolic blood pressure (117.9±11.4 vs 118.3±11.0 mm Hg, P=0.864), diastolic blood pressure (73.7±7.4 vs 74.7±8.0 mm Hg, P=0.571), mean blood pressure and heart rate between Spacelabs and Mobil-O-Graph. Correlation analyses and Bland-Altman plots showed agreement between the monitors. Overall, the participants showed a preference for the Mobil-O-Graph. Spacelabs 90217A and Mobil-O-Graph NG provide practically identical measurements during the static and ambulatory conditions in healthy individuals and can be rather used interchangeably in clinical practice.

Case report. Candida lusitaniae peritonitis in a patient on continuous ambulatory peritoneal dialysis.

PubMed

Cinar, S; Nedret Koç, A; Taşkapan, H; Dogukan, A; Tokgöz, B; Utaş, C

2002-04-01

We report a case of Candida lusitania peritonitis in continuous ambulatory peritoneal dialysis. Since fluconazole therapy was not successful in this patient, the peritoneal catheter was removed and antifungal therapy continued, and the patient was then converted to haemodialysis. This treatment protocol was successful. We suggest that early peritoneal catheter removal should be considered in such cases.

Developments in ambulatory surgery in orthopedics in France in 2016.

PubMed

Hulet, C; Rochcongar, G; Court, C

2017-02-01

Under the new categorization introduced by the Health Authorities, ambulatory surgery (AS) in France now accounts for 50% of procedures, taking all surgical specialties together. The replacement of full hospital admission by AS is now well established and recognized. Health-care centers have learned, in coordination with the medico-surgical and paramedical teams, how to set up AS units and the corresponding clinical pathways. There is no single model handed down from above. The authorities have encouraged these developments, partly by regulations but also by means of financial incentives. Patient eligibility and psychosocial criteria are crucial determining factors for the success of the AS strategy. The surgeons involved are strongly committed. Feedback from many orthopedic subspecialties (shoulder, foot, knee, spine, hand, large joints, emergency and pediatric surgery) testify to the rise of AS, which now accounts for 41% of all orthopedic procedures. Questions remain, however, concerning the role of the GP in the continuity of care, the role of innovation and teaching, the creation of new jobs, and the attractiveness of AS for surgeons. More than ever, it is the patient who is "ambulatory", within an organized structure in which surgical technique and pain management are well controlled. Not all patients can be eligible, but the AS concept is becoming standard, and overnight stay will become a matter for medical and surgical prescription. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Development of quality metrics for ambulatory pediatric cardiology: Chest pain.

PubMed

Lu, Jimmy C; Bansal, Manish; Behera, Sarina K; Boris, Jeffrey R; Cardis, Brian; Hokanson, John S; Kakavand, Bahram; Jedeikin, Roy

2017-12-01

As part of the American College of Cardiology Adult Congenital and Pediatric Cardiology Section effort to develop quality metrics (QMs) for ambulatory pediatric practice, the chest pain subcommittee aimed to develop QMs for evaluation of chest pain. A group of 8 pediatric cardiologists formulated candidate QMs in the areas of history, physical examination, and testing. Consensus candidate QMs were submitted to an expert panel for scoring by the RAND-UCLA modified Delphi process. Recommended QMs were then available for open comments from all members. These QMs are intended for use in patients 5-18 years old, referred for initial evaluation of chest pain in an ambulatory pediatric cardiology clinic, with no known history of pediatric or congenital heart disease. A total of 10 candidate QMs were submitted; 2 were rejected by the expert panel, and 5 were removed after the open comment period. The 3 approved QMs included: (1) documentation of family history of cardiomyopathy, early coronary artery disease or sudden death, (2) performance of electrocardiogram in all patients, and (3) performance of an echocardiogram to evaluate coronary arteries in patients with exertional chest pain. Despite practice variation and limited prospective data, 3 QMs were approved, with measurable data points which may be extracted from the medical record. However, further prospective studies are necessary to define practice guidelines and to develop appropriate use criteria in this population. © 2017 Wiley Periodicals, Inc.

How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings.

PubMed

Lorenzi, Nancy M; Kouroubali, Angelina; Detmer, Don E; Bloomrosen, Meryl

2009-02-23

Adoption of EHRs by U.S. ambulatory practices has been slow despite the perceived benefits of their use. Most evaluations of EHR implementations in the literature apply to large practice settings. While there are similarities relating to EHR implementation in large and small practice settings, the authors argue that scale is an important differentiator. Focusing on small ambulatory practices, this paper outlines the benefits and barriers to EHR use in this setting, and provides a "field guide" for these practices to facilitate successful EHR implementation. The benefits of EHRs in ambulatory practices include improved patient care and office efficiency, and potential financial benefits. Barriers to EHRs include costs; lack of standardization of EHR products and the design of vendor systems for large practice environments; resistance to change; initial difficulty of system use leading to productivity reduction; and perceived accrual of benefits to society and payers rather than providers. The authors stress the need for developing a flexible change management strategy when introducing EHRs that is relevant to the small practice environment; the strategy should acknowledge the importance of relationship management and the role of individual staff members in helping the entire staff to manage change. Practice staff must create an actionable vision outlining realistic goals for the implementation, and all staff must buy into the project. The authors detail the process of implementing EHRs through several stages: decision, selection, pre-implementation, implementation, and post-implementation. They stress the importance of identifying a champion to serve as an advocate of the value of EHRs and provide direction and encouragement for the project. Other key activities include assessing and redesigning workflow; understanding financial issues; conducting training that is well-timed and meets the needs of practice staff; and evaluating the implementation process. The EHR

Translating caring theory across the continuum from inpatient to ambulatory care.

PubMed

Tonges, Mary; McCann, Meghan; Strickler, Jeff

2014-06-01

While theory-based practice is a Magnet® characteristic, translating theories to practice remains challenging. As a result, theory-guided practice remains an ideal rather than a realized goal in many organizations. This article provides an overview of a research-derived caring theory, a translational model for theory-driven practice, implementation of a delivery model designed to translate theory across the acute and ambulatory care continuum, and resulting outcomes in oncology clinics and the emergency department.

Building an award-winning women's health ambulatory service and beyond.

PubMed

Allen, Lisa W; Maxwell, Susan; Greene, John F

2003-01-01

Many barriers exist for the provision of high-quality health care to inner-city minority women. The barriers include access to care, compliance problems, financial concerns, system navigation issues, as well as language barriers. This article describes the transition of the Women's Ambulatory Health Services at Hartford Hospital from a traditional clinic model to a culturally sensitive private practice model. The road to transition was paved by valuable input from staff as well as patients. The final product was a much more efficient, inviting model that catered to the needs of the community.

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…

Modelling of the optimal bupivacaine dose for spinal anaesthesia in ambulatory surgery based on data from systematic review.

PubMed

Lemoine, Adrien; Mazoit, Jean X; Bonnet, Francis

2016-11-01

Spinal bupivacaine is used for day-case surgery but the appropriate dose that guarantees hospital discharge is unknown. We sought to determine the spinal bupivacaine dose that prevents delayed hospital discharge in ambulatory surgery. Systematic review of clinical trials. Comprehensive search in electronic databases of studies published between 1996 and 2014 reporting the use of spinal bupivacaine in ambulatory patients. Additional articles were retrieved through hyperlinks and by manually searching reference lists in original articles, review articles and correspondence published in English and French. Data were used to calculate, motor block duration and discharge time, an estimated maximal effect (Emax: maximum theoretical time of motor block) and the effective dose to obtain half of Emax (D50) with 95% confidence intervals (CIs). A simulation was performed to determine the dose corresponding to a time to recovery of 300 min for motor function, and 360 min for discharge, in 95% of the patients. In total, 23 studies (1062 patients) were included for analysis of the time to recovery of motor function, and 12 studies (618 patients) for the time to hospital discharge. The Emax for recovery of motor function was 268 min [95% CI (189 to 433 min)] and the D50 was 3.9 mg [95% CI (2.3 to 6.2 mg)]. A 7.5-mg dose of bupivacaine enables resolution of motor block and ambulation within 300 min in 95% of the patients. A 5-mg dose or less was associated with an unacceptable failure rate. Ambulatory surgery is possible under spinal anaesthesia with bupivacaine although the dose range that ensures reliable anaesthesia with duration short enough to guarantee ambulatory management is narrow.

Ambulatory dysfunction due to unrecognized pernicious anemia.

PubMed

Malizia, Robert W; Baumann, Brigitte M; Chansky, Michael E; Kirchhoff, Michael A

2010-04-01

Pernicious anemia can result in significant hematologic and neurologic impairments due to a reduction in cobalamin absorption. Typically thought to be a disease of elderly whites, a growing body of literature has documented the disease in blacks and in younger age groups. We describe a case of a young black woman with gradually progressive lower extremity paresthesias, weakness, and ataxia as the primary presenting symptoms of pernicious anemia. This case is presented to make emergency physicians aware of pernicious anemia as a cause of ambulatory dysfunction in younger patients. We review the current body of literature on the diagnosis and management as well as evidence that the demographic profile of the disease is changing. Furthermore, in women of reproductive age, there is the potential for significant fetal and infant morbidity. Copyright 2010 Elsevier Inc. All rights reserved.

Analysis of National Drug Code Identifiers in Ambulatory E-Prescribing.

PubMed

Dhavle, Ajit A; Ward-Charlerie, Stacy; Rupp, Michael T; Amin, Vishal P; Ruiz, Joshua

2015-11-01

Communication of an accurate and interpretable drug identifier between prescriber and pharmacist is critically important for realizing the potential benefits of electronic prescribing (e-prescribing) while minimizing its risk. The National Drug Code (NDC) is the most commonly used codified drug identifier in ambulatory care e-prescribing, but concerns have been raised regarding its use for this purpose.  To (a) assess the frequency of NDC identifier transmission in ambulatory e-prescribing; (b) characterize the type of NDC identifier transmitted (representative, repackaged, obsolete, private label, and unit dose); and (c) assess the level of agreement between drug descriptions corresponding to NDC identifiers in electronic prescriptions (e-prescriptions) and the free-text drug descriptions that were entered by prescribers.  We analyzed a sample of 49,997 e-prescriptions that were transmitted by ambulatory care prescribers to outlets of a national retail drugstore chain during a single day in April 2014. The First Databank MedKnowledge drug database was used as the primary reference data base to assess the frequency and types of NDC numbers in the e-prescription messages. The FDA's Comprehensive NDC Standard Product Labeling Data Elements File and the National Library of Medicine's RxNorm data file were used as secondary and tertiary references, respectively, to identify NDC numbers that could not be located in the primary reference file. Three experienced reviewers compared the free-text drug description that had been entered by the prescriber with the drug description corresponding to the NDC number from 1 of the 3 reference database files to identify discrepancies. Two licensed pharmacists with residency training and ambulatory care experience served as final adjudicators. A total of 42,602 e-prescriptions contained a value in the NDC field, of which 42,335 (84.71%) were found in 1 of the 3 study reference databases and were thus considered to be valid NDC

An Analysis of Several Dimensions of Patient Safety in Ambulatory-Care Facilities

DTIC Science & Technology

2008-04-09

States were surveyed for a total sample size (N) of 213 and an overall response rate of 65%. Specialty areas, ambulatory-surgical staff, administrative...questions regarding safety. This research was limited in that it sampled only Air Force primary care staff and should certainly be replicated...What is its essence? The Greeks answered the question about substance in the sixth century with descriptions of the four fundamental elements : earth

Urologist ownership of ambulatory surgery centers and urinary stone surgery use.

PubMed

Hollingsworth, John M; Ye, Zaojun; Strope, Seth A; Krein, Sarah L; Hollenbeck, Ann T; Hollenbeck, Brent K

2009-08-01

To understand how physician ownership of ambulatory surgery centers (ASCs) relates to surgery use. Using the State Ambulatory Surgery Databases, we identified patients undergoing outpatient surgery for urinary stone disease in Florida (1998-2002). We empirically derived a measure of physician ownership and externally validated it through public data. We employed linear mixed models to examine the relationship between ownership status and surgery use. We measured how a urologist's surgery use varied by the penetration of owners within his local health care market. Owners performed a greater proportion of their surgeries in ASCs than nonowners (39.6 percent versus 8.0 percent, p<.001), and their utilization rates were over twofold higher ( p<.001). After controlling for patient differences, an owner averaged 16.32 (95 percent confidence interval [CI], 10.98-21.67; p<.001) more cases annually than did a nonowner. Further, for every 10 percent increase in the penetration of owners within a urologist's local health care market, his annual caseload increased by 3.32 (95 percent CI, 2.17-4.46; p<.001). These data demonstrate a significant association between physician ownership of ASCs and increased surgery use. While its interpretation is open to debate, one possibility relates to the financial incentives of ownership. Additional work is necessary to see if this is a specialty-specific phenomenon.

Ambulatory Holter monitoring in asymptomatic patients with DDD pacemakers - do we need ACC/AHA Guidelines revision?

PubMed

Chudzik, Michal; Klimczak, Artur; Wranicz, Jerzy Krzysztof

2013-10-31

We sought to determine the usefulness of ambulatory 24-hour Holter monitoring in detecting asymptomatic pacemaker (PM) malfunction episodes in patients with dual-chamber pacemakers whose pacing and sensing parameters were proper, as seen in routine post-implantation follow-ups. Ambulatory 24-hour Holter recordings (HM) were performed in 100 patients with DDD pacemakers 1 day after the implantation. Only asymptomatic patients with proper pacing and sensing parameters (assessed on PM telemetry on the first day post-implantation) were enrolled in the study. The following parameters were assessed: failure to pace, failure to sense (both oversensing and undersensing episodes) as well as the percentage of all PM disturbances. Despite proper sensing and pacing parameters, HM revealed PM disturbances in 23 patients out of 100 (23%). Atrial undersensing episodes were found in 12 patients (p < 0.005) with totally 963 episodes and failure to capture in 1 patient (1%). T wave oversensing was the most common ventricular channel disorder (1316 episodes in 9 patients, p < 0.0005). Malfunction episodes occurred sporadically, leading to pauses of up to 1.6 s or temporary bradycardia, which were, nevertheless, not accompanied by clinical symptoms. No ventricular pacing disturbances were found. Asymptomatic pacemaker dysfunction may be observed in nearly 25% of patients with proper DDD parameters after implantation. Thus, ambulatory HM during the early post-implantation period may be a useful tool to detect the need to reprogram PM parameters.

The relationship between dietary salt intake and ambulatory blood pressure variability in non-diabetic hypertensive patients.

PubMed

Ozkayar, Nihal; Dede, Fatih; Ates, Ihsan; Akyel, Fatma; Yildirim, Tolga; Altun, Bulent

High dietary salt intake was reported to increase blood pressure by numerous studies, but no study has investigated the effect of dietary salt intake on blood pressure variability (BPV). This study aimed to determine if daily salt intake is related to ambulatory BPV. The study included 136 primary hypertensive patients (92 male, 44 female) with a mean age of 50.7±11.1 years. All the patients underwent 24-h ambulatory blood pressure monitoring to determine both the 24-h systolic and 24-h diastolic BPV. 24-h urine sodium was measured. The correlation between BPV and 24-h urinary sodium was investigated. Logarithmic transformation of 24-h urinary sodium [log(24-h urinary sodium)] was positively correlated with the mean 24-h systolic ARV, and nighttime systolic ARV (r=0.371 and p=0.001, r=0.329 and p=0.028, respectively). Similarly, log(24-h urinary sodium) was positively correlated with mean 24-h diastolic ARV and nighttime diastolic ARV (r=0.381 and p=0.001, r=0.320 and p=0.020 respectively). Log(24-h urinary sodium) was an independent predictor of BPV based on multivariate regression analysis. Dietary salt intake might play a role in the pathogenesis of ambulatory BPV. Copyright © 2016 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

Associations Between the Continuity of Ambulatory Care of Adult Diabetes Patients in Korea and the Incidence of Macrovascular Complications.

PubMed

Gong, Young-Hoon; Yoon, Seok-Jun; Seo, Hyeyoung; Kim, Dongwoo

2015-07-01

The goal of this study was to identify association between the continuity of ambulatory care of diabetes patients in South Korea (hereafter Korea) and the incidence of macrovascular complications of diabetes, using claims data compiled by the National Health Insurance Services of Korea. This study was conducted retrospectively. The subjects of the study were 43 002 patients diagnosed with diabetes in 2007, who were over 30 years of age, and had insurance claim data from 2008. The macrovascular complications of diabetes mellitus were limited to ischemic heart disease and ischemic stroke. We compared the characteristics of the patients in whom macrovascular complications occurred from 2009 to 2012 to the characteristics of the patients who had no such complications. Multiple logistic regression was used to assess the effects of continuity of ambulatory care on diabetic macrovascular complications. The continuity of ambulatory diabetes care was estimated by metrics such as the medication possession ratio, the quarterly continuity of care and the number of clinics that were visited. Patients with macrovascular complications showed statistically significant differences regarding sex, age, comorbidities, hypertension, dyslipidemia and continuity of ambulatory diabetes care. Visiting a lower number of clinics reduced the odds ratio for macrovascular complications of diabetes. A medication possession ratio below 80% was associated with an increased odds ratio for macrovascular complications, but this result was of borderline statistical significance. Diabetes care by regular health care providers was found to be associated with a lower occurrence of diabetic macrovascular complications. This result has policy implications for the Korean health care system, in which the delivery system does not work properly.

A retrospective cross-sectional study of patients treated in US EDs and ambulatory care clinics with sexually transmitted infections from 2001 to 2010.

PubMed

Ware, Chelsea E; Ajabnoor, Yasser; Mullins, Peter M; Mazer-Amirshahi, Maryann; Pines, Jesse M; May, Larissa

2016-09-01

Sexually transmitted infections (STIs) are commonly seen in the ambulatory health care settings such as emergency departments (EDs) and outpatient clinics. Our objective was to assess trends over time in the incidence and demographics of STIs seen in the ED and outpatient clinics compared with office-based clinics using the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey. This study was conducted using 10 years of National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data (2001-2010). We compared data from 2001-2005 to data from 2006-2010. Patients were included in analyses if they were 15 years and older and had an International Classification of Diseases, Ninth Revision code consistent with cervicitis, urethritis, chlamydia, gonorrhea, or trichomonas. We analyzed 82.4 million visits for STIs, with 16.5% seen in hospital-based EDs and 83.5% seen in office-based clinics between 2001 and 2010. Compared with patients seen in office-based clinics, ED patients were younger (P< .05), more likely to be male (P< .001) and nonwhite (P< .001), and less likely to have private insurance (P< .05). We found a significant increase in adolescent (15-18 years) ED visits (P< .05) from 2001-2015 to 2006-2010 and a decrease in adolescent and male STI visits in office-based settings (P< .05). Although patients with STI are most commonly seen in office-based clinics, EDs represent an important site of care. In particular, ED patients are relatively younger, male, and nonwhite, and less likely to be private insured. Copyright © 2016 Elsevier Inc. All rights reserved.

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

The treatment of smoking by US physicians during ambulatory visits: 1994 2003.

PubMed

Thorndike, Anne N; Regan, Susan; Rigotti, Nancy A

2007-10-01

We sought to determine whether US physicians' practice patterns in treating tobacco use at ambulatory visits improved over the past decade with the appearance of national clinical practice guidelines, new smoking cessation medications, and public reporting of physician performance in counseling smokers. We compared data from the National Ambulatory Medical Care Survey, an annual survey of a random sample of office visits to US physicians, between 1994-1996 and 2001-2003. Physicians identified patients' smoking status at 68% of visits in 2001-2003 versus 65% in 1994-1996 (adjusted odds ratio [AOR]=1.16; 95% confidence interval [CI]=1.04, 1.30). Physicians counseled about smoking at 20% of smokers' visits in 2001-2003 versus 22% in 1994-1996 (AOR=0.84; 95% CI=0.71, 0.99). In both time periods, smoking cessation medication use was low (<2% of smokers' visits) and visits with counseling for smoking were longer than those without such counseling (P<.005). In the past decade, there has been a small increase in physicians' rates of patients' smoking status identification and a small decrease in rates of counseling smokers. This lack of progress may reflect barriers in the US health care environment, including limited physician time to provide counseling.

The stress-buffering effects of functional social support on ambulatory blood pressure.

PubMed

Bowen, Kimberly S; Uchino, Bert N; Birmingham, Wendy; Carlisle, McKenzie; Smith, Timothy W; Light, Kathleen C

2014-11-01

Social support is a reliable predictor of cardiovascular health. According to the buffering hypothesis, stress is 1 mechanism by which support is able to affect physiological processes. However, most of the experimental evidence for the hypothesis comes from laboratory studies. Ambulatory blood pressure (ABP) protocols examine participants in their natural environment, where they are more likely to encounter personally relevant real-world stressors. Furthermore, prior work shows that examining support by its specific functional components reveals additional independent links to health. The current study aimed to examine the stress-buffering effects of functional social support on ABP. One hundred eighty-eight participants completed a 1-day ABP assessment along with measures of functional social support and both global perceived stress and momentary stress at time of reading. RESULTS indicated main effects for both stress measures. Global support, emotional, tangible, and informational support only moderated the effects of momentary stress, but not global stress, in predicting ABP. Informational support was the most consistent stress-buffering predictor of ABP, predicting both ambulatory systolic and diastolic blood pressure. The predicted values in ABP for informational support achieved health-relevant differences, emphasizing the value of examining functional support beyond global support alone. PsycINFO Database Record (c) 2014 APA, all rights reserved.

A Single Session of Low-Volume High-Intensity Interval Exercise Reduces Ambulatory Blood Pressure in Normotensive Men.

PubMed

Dantas, Teresa C B; Farias Junior, Luiz F; Frazão, Danniel T; Silva, Paulo H M; Sousa Junior, Altieres E; Costa, Ingrid B B; Ritti-Dias, Raphael M; Forjaz, Cláudia L M; Duhamel, Todd A; Costa, Eduardo C

2017-08-01

Dantas, TCB, Farias Junior, LF, Frazão, DT, Silva, PHM, Sousa Junior, AE, Costa, IBB, Ritti-Dias, RM, Forjaz, CLM, Duhamel, TA, and Costa, EC. A single session of low-volume high-intensity interval exercise reduces ambulatory blood pressure in normotensive men. J Strength Cond Res 31(8): 2263-2269, 2017-The magnitude and duration of postexercise hypotension (PEH) may provide valuable information on the efficacy of an exercise approach to blood pressure (BP) control. We investigated the acute effect of a time-efficient high-intensity interval exercise (HIIE) on ambulatory BP. Twenty-one normotensive men (23.6 ± 3.6 years) completed 2 experimental sessions in a randomized order: (a) control (no exercise) and (b) low-volume HIIE: 10 × 1 minute at 100% of maximal treadmill velocity interspersed with 1 minute of recovery. After each experimental session, an ambulatory BP monitoring was initiated. Paired sample t-test was used to compare BP averages for awake, asleep, and 20-hour periods between the control and the low-volume HIIE sessions. A 2-way repeated measures analysis of variance was used to analyze hourly BP after both experimental sessions. Blood pressure averages during the awake (systolic: 118 ± 6 vs. 122 ± 6 mm Hg; diastolic: 65 ± 7 vs. 67 ± 7 mm Hg) and 20-hour (systolic: 115 ± 7 vs. 118 ± 6 mm Hg; diastolic: 62 ± 7 vs. 64 ± 7 mm Hg) periods were lower after the low-volume HIIE compared with the control (p ≤ 0.05). Systolic and diastolic PEH presented medium (Cohen's d = 0.50-0.67) and small (Cohen's d = 0.29) effect sizes, respectively. Systolic PEH occurred in a greater magnitude during the first 5 hours (3-5 mm Hg). No changes were found in asleep BP (p > 0.05). In conclusion, a single session of low-volume HIIE reduced ambulatory BP in normotensive men. The PEH occurred mainly in systolic BP during the first 5 hours postexercise.

Estimation of pulse rate from ambulatory PPG using ensemble empirical mode decomposition and adaptive thresholding.

PubMed

Pittara, Melpo; Theocharides, Theocharis; Orphanidou, Christina

2017-07-01

A new method for deriving pulse rate from PPG obtained from ambulatory patients is presented. The method employs Ensemble Empirical Mode Decomposition to identify the pulsatile component from noise-corrupted PPG, and then uses a set of physiologically-relevant rules followed by adaptive thresholding, in order to estimate the pulse rate in the presence of noise. The method was optimized and validated using 63 hours of data obtained from ambulatory hospital patients. The F1 score obtained with respect to expertly annotated data was 0.857 and the mean absolute errors of estimated pulse rates with respect to heart rates obtained from ECG collected in parallel were 1.72 bpm for "good" quality PPG and 4.49 bpm for "bad" quality PPG. Both errors are within the clinically acceptable margin-of-error for pulse rate/heart rate measurements, showing the promise of the proposed approach for inclusion in next generation wearable sensors.

A survey on signals and systems in ambulatory blood pressure monitoring using pulse transit time.

PubMed

Buxi, Dilpreet; Redouté, Jean-Michel; Yuce, Mehmet Rasit

2015-03-01

Blood pressure monitoring based on pulse transit or arrival time has been the focus of much research in order to design ambulatory blood pressure monitors. The accuracy of these monitors is limited by several challenges, such as acquisition and processing of physiological signals as well as changes in vascular tone and the pre-ejection period. In this work, a literature survey covering recent developments is presented in order to identify gaps in the literature. The findings of the literature are classified according to three aspects. These are the calibration of pulse transit/arrival times to blood pressure, acquisition and processing of physiological signals and finally, the design of fully integrated blood pressure measurement systems. Alternative technologies as well as locations for the measurement of the pulse wave signal should be investigated in order to improve the accuracy during calibration. Furthermore, the integration and validation of monitoring systems needs to be improved in current ambulatory blood pressure monitors.

Circadian phase assessment by ambulatory monitoring in humans: correlation with dim light melatonin onset.

PubMed

Bonmati-Carrion, M A; Middleton, B; Revell, V; Skene, D J; Rol, M A; Madrid, J A

2014-02-01

The increased prevalence of circadian disruptions due to abnormal coupling between internal and external time makes the detection of circadian phase in humans by ambulatory recordings a compelling need. Here, we propose an accurate practical procedure to estimate circadian phase with the least possible burden for the subject, that is, without the restraints of a constant routine protocol or laboratory techniques such as melatonin quantification, both of which are standard procedures. In this validation study, subjects (N = 13) wore ambulatory monitoring devices, kept daily sleep diaries and went about their daily routine for 10 days. The devices measured skin temperature at wrist level (WT), motor activity and body position on the arm, and light exposure by means of a sensor placed on the chest. Dim light melatonin onset (DLMO) was used to compare and evaluate the accuracy of the ambulatory variables in assessing circadian phase. An evening increase in WT: WTOnset (WTOn) and "WT increase onset" (WTiO) was found to anticipate the evening increase in melatonin, while decreases in motor activity (Activity Offset or AcOff), body position (Position Offset (POff)), integrative TAP (a combination of WT, activity and body position) (TAPOffset or TAPOff) and an increase in declared sleep propensity were phase delayed with respect to DLMO. The phase markers obtained from subjective sleep (R = 0.811), WT (R = 0.756) and the composite variable TAP (R = 0.720) were highly and significantly correlated with DLMO. The findings strongly support a new method to calculate circadian phase based on WT (WTiO) that accurately predicts and shows a temporal association with DLMO. WTiO is especially recommended due to its simplicity and applicability to clinical use under conditions where knowing endogenous circadian phase is important, such as in cancer chronotherapy and light therapy.

Diagnostic accuracy of manual office blood pressure measurement in ambulatory hypertensive patients in Korea.

PubMed

Kim, Sehun; Park, Jin Joo; Lee, Seung-Ah; Cho, Youngjin; Yoon, Yeonyee E; Oh, Il-Young; Yoon, Chang-Hwan; Suh, Jung-Won; Cho, Young-Seok; Youn, Tae-Jin; Cho, Goo-Yeong; Chae, In-Ho; Lee, Hae-Young; Shin, Jinho; Park, Sungha; Choi, Dong-Ju

2018-01-01

Currently, office blood pressure (OBP) is the most widely used method of measuring blood pressure (BP) in daily clinical practice. However, data on the diagnostic accuracy of OBP in reference to ambulatory blood pressure (ABP) are scarce in Korea. In retrospective and prospective cohorts, manual OBP and ABP measurements were compared among ambulatory hypertensive patients. Hypertension was defined as systolic OBP ≥ 140 mmHg and/or diastolic OBP ≥ 90 mmHg, and systolic ABP ≥ 130 mmHg and/or diastolic ABP ≥ 80 mmHg. In the retrospective cohort (n = 903), the mean OBP1 (before ABP measurement) was higher than ABP in both systolic (138 ± 17 mmHg vs. 123 ± 13 mmHg, p < 0.001) and diastolic (84 ± 12 mmHg vs. 78 ± 11 mmHg, p < 0.001) measurements. Interestingly, there was only a weak correlation between OBP and ABP ( r 2 = 0.038, p < 0.001). The overall discordance rate of OBP compared to ABP, which is the reference method for measuring BP, was 43.9%. The prospective cohort (n = 57) showed similar results. In a subgroup analysis, male patients had higher false negative results (masked or under-treated hypertension) than did female patients (26.1% vs. 17.8%, p = 0.003), whereas female patients had a higher false positive rate (white-coat or over-treated hypertension) than did male patients (28.7% vs. 15.2%, p < 0.001). The diagnostic accuracy of manual OBP is low in reference to ABP. Men and women have different patterns of discordance. These findings indicate that management of hypertensive patients with manual OBP measurements may be suboptimal and encourages the use of ABP in ambulatory hypertensive patients.

Validating hyperbilirubinemia and gut mucosal atrophy with a novel ultramobile ambulatory total parenteral nutrition piglet model

USDA-ARS?s Scientific Manuscript database

Total parenteral nutrition (TPN) provides all nutrition intravenously. Although TPN therapy has grown enormously, it causes significant complications, including gut and hepatic dysfunction. Current models use animal tethering which is unlike ambulatory human TPN delivery and is cost prohibitive. We ...

A device for 24 hour ambulatory monitoring of abdominal girth using inductive plethysmography.

PubMed

Reilly, B P; Bolton, M P; Lewis, M J; Houghton, L A; Whorwell, P J

2002-11-01

Inductive plethysmography (IP) sensors and oscillator modules were assessed for their potential use in the ambulatory monitoring of abdominal girth in subjects with irritable bowel syndrome (IBS) in order to objectively quantify their bloating symptoms. A dedicated microprocessordata logger was designed to record over 24 h the frequency output of IP oscillators connected to a belt around the subject's lower abdomen. Posture was also recorded via tilt switches (standing, sitting and lying). The system was separately calibrated by placing the belts around a variable rectangular phantom and measuring the frequency of oscillation. A theoretical geometric model was devised to convert measured frequency into circumference and account for changes caused by variations in shape. Using the calibration factors, it was found that the circumference of a circular phantom could be measured accurately (mean difference 1.27 cm and SD 0.25 cm). The system has been tested over 24 h with 20 volunteers. Movement introduced variations in measured girth larger than those found during periods of non-movement during sleep. We conclude that IP promises to be a useful and quantitative tool suitable for ambulatory monitoring of abdominal girth, a hitherto relatively unexplored symptom of IBS.

Clinical differences among nonsteroidal antiinflammatory drugs: implications for therapeutic substitution in ambulatory patients.

PubMed

Levy, R A; Smith, D L

1989-01-01

The practice of therapeutic substitution, i.e., replacing one drug with another chemically different drug from the same therapeutic class, represents an important therapeutic modification with potential clinical significance far beyond that of generic substitution. Adverse consequences following therapeutic substitution of nonsteroidal antiinflammatory drugs (NSAID) is of special concern because of substantial differences among these agents in pharmacokinetic, pharmacological, and clinical properties. Therapeutic substitution of NSAID for ambulatory patients may result in compromised clinical outcome because (1) patient response is unpredictable and selection of the optimal agent must be tailored for each patient; (2) substantial differences exist in adverse reaction profiles; (3) drug interaction studies are lacking; and (4) selection of an agent must be individualized to ensure compliance with the dosing regimen. Cost savings achieved through therapeutic substitution of NSAID may be lost by additional overall treatment costs due to adverse reactions or suboptimal therapy. The occurrence of adverse or suboptimal effects in ambulatory patients is more likely if NSAID are substituted without full knowledge of the patient's medical history and clinical status. Communication between the pharmacy and prescribing physician regarding a patient's specific needs is essential for rational substitution among NSAID.

Comparing team-based and mixed active-learning methods in an ambulatory care elective course.

PubMed

Zingone, Michelle M; Franks, Andrea S; Guirguis, Alexander B; George, Christa M; Howard-Thompson, Amanda; Heidel, Robert E

2010-11-10

To assess students' performance and perceptions of team-based and mixed active-learning methods in 2 ambulatory care elective courses, and to describe faculty members' perceptions of team-based learning. Using the 2 teaching methods, students' grades were compared. Students' perceptions were assessed through 2 anonymous course evaluation instruments. Faculty members who taught courses using the team-based learning method were surveyed regarding their impressions of team-based learning. The ambulatory care course was offered to 64 students using team-based learning (n = 37) and mixed active learning (n = 27) formats. The mean quality points earned were 3.7 (team-based learning) and 3.3 (mixed active learning), p < 0.001. Course evaluations for both courses were favorable. All faculty members who used the team-based learning method reported that they would consider using team-based learning in another course. Students were satisfied with both teaching methods; however, student grades were significantly higher in the team-based learning course. Faculty members recognized team-based learning as an effective teaching strategy for small-group active learning.

Does procedure profitability impact whether an outpatient surgery is performed at an ambulatory surgery center or hospital?

PubMed

Plotzke, Michael Robert; Courtemanche, Charles

2011-07-01

Ambulatory surgery centers (ASCs) are small (typically physician owned) healthcare facilities that specialize in performing outpatient surgeries and therefore compete against hospitals for patients. Physicians who own ASCs could treat their most profitable patients at their ASCs and less profitable patients at hospitals. This paper asks if the profitability of an outpatient surgery impacts where a physician performs the surgery. Using a sample of Medicare patients from the National Survey of Ambulatory Surgery, we find that higher profit surgeries do have a higher probability of being performed at an ASC compared to a hospital. After controlling for surgery type, a 10% increase in a surgery's profitability is associated with a 1.2 to 1.4 percentage point increase in the probability the surgery is performed at an ASC. Copyright © 2010 John Wiley & Sons, Ltd.

Patterns of ambulatory medical care utilization and rheumatologist consultation predating the diagnosis of systemic lupus erythematosus: a national population-based study.

PubMed

Lai, Ning-Sheng; Tsai, Tzung-Yi; Koo, Malcolm; Huang, Kuang-Yung; Tung, Chien-Hsueh; Lu, Ming-Chi

2014-01-01

To investigate the records of ambulatory medical care from patients predating the diagnosis of systemic lupus erythematosus (SLE) using nationwide, population-based claims data. 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. 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. 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 screened with tools such as the antinuclear

Ambulatory blood pressure monitoring in healthy children with parental hypertension.

PubMed

Alpay, Harika; Ozdemir, Nihal; Wühl, Elke; Topuzoğlu, Ahmet

2009-01-01

The aim of this study was to compare ambulatory blood pressure monitoring (ABPM) parameters in offspring with at least one hypertensive parent (HP) to offspring with normotensive parents (NP) and to determine whether gender of parent or child might influence the association between parental hypertension and blood pressure (BP). Eighty-nine healthy children (mean age 11.1 +/- 3.9 years) with HP and 90 controls (mean age 10.5 +/- 3.1 years) with NP were recruited. Age, gender, and height did not differ between the two groups, whereas children of HP had higher weight, body mass index (BMI), and waist circumference compared with healthy controls. No difference was found in casual BP between the two groups. In contrast, during ABPM daytime and nighttime mean systolic and diastolic BP and mean arterial pressure (MAP) standard deviation scores (SDS) were significantly elevated in children with HP. The mean percentage of nocturnal BP decline (dipping) was not significantly different between the two groups. Children with hypertensive mothers had higher daytime systolic and MAP SDS than controls; no such difference was detected for children with hypertensive fathers. Daytime systolic and MAP SDS were significantly elevated in boys with HP compared with boys with NP but failed to be significant in girls. Multiple linear regression analysis showed that parental history of hypertension (B = 0.29) and BMI (B = 0.03) were independently correlated with increase of daytime MAP SDS. Early changes in ambulatory BP parameters were present in healthy children of HP. BP in HP offspring was influenced by the gender of the affected parent and the offspring.

Two Cases of Peritonitis Caused by Kocuria marina in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis▿

PubMed Central

Lee, Ja Young; Kim, Si Hyun; Jeong, Haeng Soon; Oh, Seung Hwan; Kim, Hye Ran; Kim, Yeong Hoon; Lee, Jeong Nyeo; Kook, Joong-Ki; Kho, Weon-Gyu; Bae, Il Kwon; Shin, Jeong Hwan

2009-01-01

Kocuria spp. are members of the Micrococcaceae family that are frequently found in the environment and on human skin. Few human infections have been reported. We describe what appear to be the first two cases of Kocuria marina peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. PMID:19692561

[Low-power Wireless Micro Ambulatory Electrocardiogram Node].

PubMed

Cai, Zhipeng; Luo, Kan; Li, Jianqing

2016-02-01

Ambulatory electrocardiogram (ECG) monitoring can effectively reduce the risk and death rate of patients with cardiovascular diseases (CVDs). The Body Sensor Network (BSN) based ECG monitoring is a new and efficien method to protect the CVDs patients. To meet the challenges of miniaturization, low power and high signal quality of the node, we proposed a novel 50 mmX 50 mmX 10 mm, 30 g wireless ECG node, which includes the single-chip an alog front-end AD8232, ultra-low power microprocessor MSP430F1611 and Bluetooth module HM-11. The ECG signal quality is guaranteed by the on-line digital filtering. The difference threshold algorithm results in accuracy of R-wave detection and heart rate. Experiments were carried out to test the node and the results showed that the pro posed node reached the design target, and it has great potential in application of wireless ECG monitoring.

Anatomical and procedural determinants of ambulatory blood pressure lowering following catheter-based renal denervation using radiofrequency.

PubMed

Lauder, Lucas; Ewen, Sebastian; Tzafriri, Abraham R; Edelman, Elazer R; Cremers, Bodo; Kulenthiran, Saarraaken; Ukena, Christian; Linz, Dominik; Kindermann, Ingrid; Tsioufis, Costas; Scheller, Bruno; Böhm, Michael; Mahfoud, Felix

2018-03-02

Catheter-based renal sympathetic denervation (RDN) has been introduced to lower blood pressure (BP) and sympathetic activity in patients with uncontrolled hypertension with at best equivocal results. It has been postulated that anatomic and procedural elements introduce unaccounted variability and yet little is known of the impact of renal anatomy and procedural parameters on BP response to RDN. Anatomical parameters such as length and diameter were analyzed by quantitative vascular analysis and the prevalence of accessory renal arteries and renal artery disease were documented in 150 patients with resistant hypertension undergoing bilateral RDN using a mono-electrode radiofrequency catheter (Symplicity Flex, Medtronic). Accessory renal arteries and renal artery disease were present in 56 (37%) and 14 patients (9%), respectively. At 6-months, 24 h-ambulatory BP was reduced by 11/6 mm Hg (p < 0.001 for both). Change of systolic blood pressure (SBP) was not related to the presence of accessory renal arteries (p = 0.543) or renal artery disease (p = 0.598). Patients with at least one main renal artery diameter ≤ 4 mm had a more pronounced reduction of 24 h-ambulatory SBP compared to patients where both arteries were >4 mm (-19 vs. -10 mmHg; p = 0.038). Neither the length of the renal artery nor the number of RF ablations influenced 24 h-ambulatory BP reduction at 6 months. 24 h-ambulatory BP lowering was most pronounced in patients with smaller renal artery diameter but not related to renal artery length, accessory arteries or renal artery disease. Further, there was no dose-response relationship observed with increasing number of ablations. Because little is known of the impact of renal anatomy and procedural parameters on blood pressure (BP) response to renal denervation (RDN), anatomical and procedural data were analyzed in 150 patients undergoing bilateral RDN. BP lowering was most pronounced in patients with smaller renal

HMO penetration, hospital competition, and growth of ambulatory surgery centers.

PubMed

Bian, John; Morrisey, Michael A

2006-01-01

Using metropolitan statistical area (MSA) panel data from 1992-2001 constructed from the 2002 Medicare Online Survey Certification and Reporting (OSCAR) System, we estimate the market effects of health maintenance organization (HMO) penetration and hospital competition on the growth of freestanding ambulatory surgery centers (ASCs). Our regression models with MSA and year fixed effects suggest that a 10-percentage-point increase in HMO penetration is associated with a decrease of 3 ASCs per 1 million population. A decrease from 5 to 4 equal-market-shared hospitals in a market is associated with an increase of 2.5 ASCs per 1 million population.

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.

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.

PubMed

Sinsky, Christine; Colligan, Lacey; Li, Ling; Prgomet, Mirela; Reynolds, Sam; Goeders, Lindsey; Westbrook, Johanna; Tutty, Michael; Blike, George

2016-12-06

Little is known about how physician time is allocated in ambulatory care. To describe how physician time is spent in ambulatory practice. Quantitative direct observational time and motion study (during office hours) and self-reported diary (after hours). U.S. ambulatory care in 4 specialties in 4 states (Illinois, New Hampshire, Virginia, and Washington). 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries. Proportions of time spent on 4 activities (direct clinical face time, electronic health record [EHR] and desk work, administrative tasks, and other tasks) and self-reported after-hours work. During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks. Data were gathered in self-selected, high-performing practices and may not be generalizable to other settings. The descriptive study design did not support formal statistical comparisons by physician and practice characteristics. For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. American Medical Association.

Productivity and cost implications of implementing electronic medical records into an ambulatory surgical subspecialty clinic.

PubMed

Patil, Mukul; Puri, Lalit; Gonzalez, Chris M

2008-02-01

Electronic medical records (EMRs) have been proposed as technology through which the quality of healthcare could be improved. We present an analysis of the cost and productivity implications associated with the transition from transcription to an EMR system in an ambulatory setting. Data were collected from eight consecutive fiscal years from 1998 to 2005. Transcription was used in the first 4-year period, and EMR was implemented and used in the later 4-year period. Productivity was defined as ambulatory revenue and the number of patient encounters. All costs related to transcription and EMR implementation were calculated. All data were adjusted for inflation. Within the transcription era, the transcription costs were $395,404, total revenue was $18,137,945, and patient encounters numbered 52,027. The average transcription cost per encounter was $7.60, average revenue per encounter was $348.63, and average revenue per provider was $505,615. Within the EMR era, the EMR-related costs were $293,406, total revenue was $30,370,647 and patient encounters numbered 65,102. The average documentation cost per encounter was $4.51, average revenue per encounter was $466.51, and average revenue per provider was $690,242. The startup costs of initial EMR implementation were $10,329 per physician provider. The results of our study have shown that the implementation of an EMR system when an economy of scale exists coincides with an increase in the revenue per encounter and per provider compared with transcription. The advantage of the fixed costs of an EMR system compared with the variable costs of a transcription-based system is the allowance of cash savings in an ambulatory surgical subspecialty practice.

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.

An efficient and effective teaching model for ambulatory education.

PubMed

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

2002-07-01

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

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.

Shifts in nursing and medical student's attitudes, beliefs and behaviours about interprofessional work: An interprofessional placement in ambulatory care.

PubMed

Seaman, Karla; Saunders, Rosemary; Dugmore, Helen; Tobin, Claire; Singer, Rachel; Lake, Fiona

2018-05-12

To examine students' beliefs, behaviours and attitudes in relation to interprofessional socialisation, and their expectations and experience, before and after a two-week clinical placement in ambulatory care. Interprofessional clinical placements for students are important for developing an understanding of interprofessional collaboration and identity, for the benefit of patient care. Ambulatory care environment involves collaborative management of complex chronic problems. This educator supported placement enabled final year nursing and medical students to work together. A descriptive matched pre-post study was conducted. Students' completed an online questionnaire pre and post their clinical placement. The questionnaire comprised of three sections; demographic information, the Interprofessional Socialisation and Valuing Scale and open-ended questions. Descriptive analysis and paired t-tests were conducted for the three subscales and thematic analysis of qualitative responses was conducted. Sixty-two of the 151 students between 2011-2014 completed both surveys. There was a significant increase post placement in the overall Interprofessional Socialisation and Valuing Scale scores. The change was greater for nursing students compared with medical students, although for both groups the change was small. The majority had a good to very good experience learning each other's and their own professions, and identified the Nurse Educator and Teaching Registrar as key to success. A clinical placement in an ambulatory setting for nursing and medical students resulted in an increase in self-perceived ability to work with others and in valuing working with others. Interprofessional clinical placements are essential for students to understand interprofessional practice for better patient outcomes and developing their own perspective of future work within an interprofessional team. Ambulatory care is an ideal environment for nursing and other health professional students to

Symmetric ambulatory arterial stiffness index and 24-h pulse pressure in HIV infection: results of a nationwide cross-sectional study.

PubMed

Schillaci, Giuseppe; Maggi, Paolo; Madeddu, Giordano; Pucci, Giacomo; Mazzotta, Elena; Penco, Giovanni; Orofino, Giancarlo; Menzaghi, Barbara; Rusconi, Stefano; Carenzi, Laura; Celesia, Benedetto M; Martinelli, Canio; Bonfanti, Paolo; De Socio, Giuseppe Vittorio

2013-03-01

HIV infection has been associated with increased cardiovascular risk. Twenty-four-hour ambulatory blood pressure (BP) is a more accurate and prognostically relevant measure of an individual's BP load than office BP, and the ambulatory BP-derived ambulatory arterial stiffness index (AASI) and symmetric AASI (s-AASI) are established cardiovascular risk factors. In the setting of the HIV and HYpertension (HIV-HY) study, an Italian nationwide survey on high BP in HIV infection, 100 HIV-infected patients with high-normal BP or untreated hypertension (72% men, age 48 ± 10 years, BP 142/91 ± 12/7 mmHg) and 325 HIV-negative individuals with comparable age, sex distribution, and office BP (68% men, age 48 ± 10 years, BP 141/90 ± 11/8 mmHg) underwent 24-h ambulatory BP monitoring. Despite having similar office BP, HIV-infected individuals had higher 24-h SBP (130.6 ± 14 vs. 126.4 ± 10 mmHg) and pulse pressure (49.1 ± 9 vs. 45.9 ± 7 mmHg, both P < 0.001), and a lower day-night reduction of mean arterial pressure (14.3 ± 9 vs. 16.3 ± 7%, P = 0.025). Both s-AASI and AASI were significantly higher in HIV patients (s-AASI, 0.22 ± 0.18 vs. 0.11 ± 0.15; AASI, 0.46 ± 0.22 vs. 0.29 ± 0.17; both P <0.001). In a multivariate regression, s-AASI was independently predicted by HIV infection (β = 0.252, P <0.001), age, female sex, and 24-h SBP. In HIV patients, s-AASI had an inverse relation with CD4 cell count (Spearman's ρ -0.24, P = 0.027). Individuals with HIV infection and borderline or definite hypertension have higher symmetric AASI and 24-h systolic and pulse pressures than HIV-uninfected controls matched by office BP. High ambulatory BP may play a role in the HIV-related increase in cardiovascular risk.

Arterial stiffness and its relationship to clinic and ambulatory blood pressure: a longitudinal study in non-dialysis chronic kidney disease.

PubMed

Agarwal, Rajiv

2017-11-01

Both arterial stiffness and systolic blood pressure (BP) are established cardiovascular risk factors, yet little is known about their interrelationship in chronic kidney disease (CKD). The goal of this prospective study was to describe the trajectory of aortic pulse wave velocity (PWV) and BP and to compare the longitudinal interrelationship of BP (clinic and 24 h ambulatory recording) with the PWV. Clinic BP was taken in two ways: at the time of the measurement of the PWV (Clinic-S) and as an average of triplicate measurements on three separate occasions within 1 week (Clinic-M). 24 h ambulatory BP was measured using a validated monitor and PWV was measured in the aorta using an echo-Doppler technique. Among 255 veterans with CKD followed for over up to 4 years, the rate of change of log PWV was inversely related to the baseline PWV; the trajectories were variable among individuals and the net population change was no different from zero. In contrast, systolic BP significantly increased, but linearly, and a strong relationship was seen between cross-sectional and longitudinal changes in Clinic-M systolic BP and log PWV. In contrast, a longitudinal relationship between Clinic-S and log PWV was absent. In the case of 24-h ambulatory BP, a strong cross-sectional change was seen between awake and 24 h systolic BP but not between sleep BP and log PWV. In conclusion, among people with CKD, the PWV changes over time and is inversely related to the baseline PWV. An average of clinic BP measurements taken over three visits, but not single measurements, are useful to assess the PWV and its change over time. Differences exist between ambulatory BP monitoring recording during the sleep and awake states in their ability to predict the PWV. Taken together, these data support the view that among those with CKD not on dialysis, targeting clinic BP taken on multiple occasions using a standardized methodology or daytime ambulatory systolic BP may slow the progression of arterial

Prevalence of vitamin D insufficiency in elderly ambulatory outpatients in Denver, Colorado.

PubMed

Linnebur, Sunny A; Vondracek, Sheryl F; Vande Griend, Joseph P; Ruscin, J Mark; McDermott, Michael T

2007-03-01

Vitamin D insufficiency is common in the elderly. However, previous studies have utilized 25-hydroxvvitamin D (25[OH]D) concentrations as low as <16 ng/mL for defining vitamin D insufficiency. Moreover, most of the studies have been conducted in European patients, in certain geographic areas of the United States, or in institutionalized elderly. The goal of this study was to characterize vitamin D concentrations in ambulatory elderly living in metropolitan Denver, Colorado, utilizing 25(OH)D concentrations <32 ng/mL as the definition for vitamin D insufficiency. Ambulatory older adults (aged 65-89 years) with clinic visits during December 2005 and January 2006 were enrolled. Serum concentrations of 25(OH)D, parathyroid hormone (PTH), calcium, phosphorus, creatinine, and albumin were measured; height and weight were also measured. Data regarding dietary and over-the-counter vitamin D intake were collected, as well as information on body mass index, history of osteoporosis, osteoporosis treatment, and history of falls and fractures. Eighty patients (mean [SD] age, 77.8 [5.3] years; age range, 66-89 years) completed the study; there were no dropouts. The majority of patients were white (88%) and female (68%). Fifty-nine (74%) were found to have vitamin D insufficiency. Mean total and over-the-counter vitamin D intake was significantly higher in sufficient (P < 0.01) and insufficient (P < 0.05) patients compared with deficient patients, but dietary intake did not differ significantly between groups. The majority of patients who were vitamin D insufficient consumed more than the recommended 400 to 600 IU/d of vitamin D. Obese patients were found to have significantly lower 25(OH)D concentrations (P < 0.001) and higher PTH concentrations (P = 0.04) than nonobese patients. Vitamin D insufficiency is prevalent in ambulatory, and especially obese, elderly living in Denver, Colorado, despite vitamin D intake consistent with national recommendations. Dietary intake of vitamin

Ambulatory Surgery Centers and Prices in Hospital Outpatient Departments.

PubMed

Carey, Kathleen

2017-04-01

Specialty providers claim to offer a new competitive benchmark for efficient delivery of health care. This article explores this view by examining evidence for price competition between ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs). I studied the impact of ASC market presence on actual prices paid to HOPDs during 2007-2010 for four common surgical procedures that were performed in both provider types. For the procedures examined, HOPDs received payments from commercial insurers in the range of 3.25% to 5.15% lower for each additional ASC per 100,000 persons in a market. HOPDs may have less negotiating leverage with commercial insurers on price in markets with high ASC market penetration, resulting in relatively lower prices.

Longitudinal Study of Left Ventricular Mass Growth: Comparative Study of Clinic and Ambulatory Systolic Blood Pressure in Chronic Kidney Disease.

PubMed

Agarwal, Rajiv

2016-04-01

Left ventricular (LV) hypertrophy is an established cardiovascular risk factor, yet little is known about its trajectory in people with chronic kidney disease. The goal of this prospective research study was to describe the trajectory of LV mass index, its relationship with blood pressure (BP), and specifically to compare the relationship of BP measured in the clinic and 24-hour ambulatory BP monitoring with LV mass index. Among 274 veterans with chronic kidney disease followed for over ≤ 4 years, the rate of growth of log LV mass index was inversely related to baseline LV mass index; it was rapid in the first 2 years, and plateaued subsequently. Systolic BP also significantly increased, but linearly, 1.7 mm Hg/y by clinic measurements and 1.8 mm Hg/y by 24-hour ambulatory BP. Cross-sectional and longitudinal associations of both clinic BP and 24-hour ambulatory BP with LV mass index were similar; both BP recording methods were associated with LV mass index and its growth over time. Controlled hypertension, masked uncontrolled hypertension, and uncontrolled hypertension categories had increasing LV mass index when diagnosed by 24-hour ambulatory and awake BP (P<0.05 for linear trend) but not sleep BP. After accounting for clinic BP both at baseline and longitudinally, LV mass index among individuals was additionally predicted by the difference in sleep systolic BP and clinic systolic BP (P=0.032). In conclusion, among people with chronic kidney disease, the growth of LV mass index is rapid. Research-grade clinic BP is useful to assess LV mass index and its growth over time. © 2016 American Heart Association, Inc.

Long-Term Follow-Up After Penicillin Allergy Delabeling in Ambulatory Patients.

PubMed

Lachover-Roth, Idit; Sharon, Shoshan; Rosman, Yossi; Meir-Shafrir, Keren; Confino-Cohen, Ronit

2018-05-22

Unverified penicillin allergy label has negative health implications. To address this, several delabeling methods have been proposed. To appraise the long-term outcomes of the penicillin allergy evaluation in ambulatory patients, focusing on subsequent use of penicillins in individuals found not allergic. A secondary objective was to examine the consistency between the evaluation's recommendations and the allergy label. A retrospective medical records review and phone survey were carried out in ambulatory patients who were evaluated for suspected penicillin allergy in our allergy unit. Patients with an uneventful oral challenge test (OCT) were interviewed regarding subsequent use of penicillins. Medical records were examined for antibiotic prescriptions and purchases. The records were also investigated for existing/erased penicillin allergy label and its consistency with the allergy evaluation. Six hundred thirty-nine patients with an uneventful OCT were available for the survey. During a 56-month follow-up, 70% (447 patients) had used penicillins at least once. One hundred ninety-two patients (30%) did not use penicillins. The main reason for not using penicillins was lack of a clinical indication. Three hundred thirty-five patients (51.22%) carried a penicillin allergy label in their electronic medical file in spite of an uneventful OCT. Penicillin allergy annulling via OCT has proven to be effective. Most of the patients who previously avoided penicillins have reused penicillins safely. Copyright © 2018 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Effects of the novel norepinephrine prodrug, droxidopa, on ambulatory blood pressure in patients with neurogenic orthostatic hypotension.

PubMed

Kaufmann, Horacio; Norcliffe-Kaufmann, Lucy; Hewitt, L Arthur; Rowse, Gerald J; White, William B

2016-10-01

The prodrug droxidopa increases blood pressure (BP) in patients with neurogenic orthostatic hypotension. The BP profile of droxidopa in neurogenic orthostatic hypotension patients (n = 18) was investigated using ambulatory BP monitoring. Following dose optimization and a washout period, 24-hour "off-drug" data were collected. "On-drug" assessment was conducted after 4-5 weeks of droxidopa treatment (mean dose, 444 mg, three times daily). Ambulatory monitoring off drug revealed that 90% of patients already had abnormalities in the circadian BP profile and did not meet criteria for normal nocturnal BP dipping. On treatment, both overall mean 24-hour systolic and diastolic BPs were higher compared to off drug (137/81 mm Hg vs. 129/76 mm Hg; P = .017/.002). Mean daytime systolic BP was significantly higher with droxidopa (8.4 ± 3.1 mm Hg; P = .014). Although nocturnal BP was not significantly higher on droxidopa versus off treatment (P = .122), increases in nocturnal (supine) BP ≥10 mm Hg were observed in four cases (22%). Severe supine systolic hypertensive readings at night (>200 mm Hg) were captured in one case and only while on treatment. These data demonstrate that ambulatory BP monitoring is useful to evaluate the circadian BP profile after initiating treatment with a pressor agent. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Institutional charges and disparities in outpatient brain biopsies in four US States: the State Ambulatory Database (SASD).

PubMed

Bekelis, Kimon; Missios, Symeon; Roberts, David W

2013-11-01

Several groups have demonstrated the safety of ambulatory brain biopsies, with no patients experiencing complications related to early discharge. Although they appear to be safe, the reasons factoring into the selection of patients have not been investigated. We performed a cross-sectional study involving 504 patients who underwent outpatient and 10,328 patients who underwent inpatient brain biopsies and were registered in State Ambulatory Surgery Databases and State Inpatient Databases respectively for four US States (New York, California, Florida, North Carolina). In a multivariate analysis private insurance (OR 2.45, 95 % CI, 1.85, 3.24), was significantly associated with outpatient procedures. Higher Charlson Comorbidity Index (OR 0.16, 95 % CI, 0.08, 0.32), high income (OR 0.37, 95 % CI, 0.26, 0.53), and high volume hospitals (OR 0.30, 95 % CI, 0.23, 0.39) were associated with a decreased chance of outpatient procedures. No sex, or racial disparities were observed. Institutional charges were significantly less for outpatient brain biopsies. There was no difference in the rate of 30-day postoperative readmissions among inpatient and outpatient procedures. The median charge for inpatient surgery was 51,316 as compared to 12,266 for the outpatient setting (P < 0.0001, Student's t test). Access to ambulatory brain biopsies appears to be more common for patients with private insurance and less comorbidities, in the setting of lower volume hospitals. Further investigation is needed in the direction of mapping these disparities in resource utilization.

The Efficacy of Lavender Aromatherapy in Reducing Preoperative Anxiety in Ambulatory Surgery Patients Undergoing Procedures in General Otolaryngology

PubMed Central

Wotman, Michael; Levinger, Joshua; Leung, Lillian; Kallush, Aron; Mauer, Elizabeth

2017-01-01

Background Preoperative anxiety is a common problem in hospitals and other health care centers. This emotional state has been shown to negatively impact patient satisfaction and outcomes. Aromatherapy, the therapeutic use of essential oils extracted from aromatic plants, may offer a simple, low‐risk and cost‐effective method of managing preoperative anxiety. The purpose of this study was to evaluate the efficacy of lavender aromatherapy in reducing preoperative anxiety in ambulatory surgery patients undergoing procedures in general otolaryngology. Methods A prospective and controlled pilot study was conducted with 100 patients who were admitted to New York‐Presbyterian/Weill Cornell Medical Center for ambulatory surgery from January of 2015 to August of 2015. The subjects were allocated to two groups; the experimental group received inhalation lavender aromatherapy in the preoperative waiting area while the control group received standard nursing care. Both groups reported their anxiety with a visual analog scale (VAS) upon arriving to the preoperative waiting area and upon departure to the operating room. Results According to a Welch's two sample t‐test, the mean reduction in anxiety was statistically greater in the experimental group than the control group (p = 0.001). Conclusion Lavender aromatherapy reduced preoperative anxiety in ambulatory surgery patients. This effect was modest and possibly statistically significant. Future research is needed to confirm the clinical efficacy of lavender aromatherapy. Level of Evidence 2b PMID:29299520

School burnout: increased sympathetic vasomotor tone and attenuated ambulatory diurnal blood pressure variability in young adult women.

PubMed

May, Ross W; Sanchez-Gonzalez, Marcos A; Fincham, Frank D

2015-01-01

Two studies examined autonomic and cardiovascular functioning that may link school burnout to cardiovascular risk factors in young healthy adult females. Study 1 (N = 136) investigated whether school burnout was related to resting values of blood pressure (BP) and blood pressure variability (BPV) through laboratory beat-to-beat BP assessment. Study 2 (N = 94) examined the link between school burnout and diurnal BPV through ambulatory BP monitoring. Controlling for anxiety and depressive symptomatology, school burnout demonstrated strong positive relationships with indices of cardiac sympathovagal tone, sympathetic vasomotor tone, inefficient myocardial oxygen consumption, increased 24-h ambulatory heart rate and BP, blunted BP diurnal variability, and increased arterial stiffness. These studies establish cardiovascular biomarkers of school burnout and suggest that even in a seemingly healthy sample school burnout may predispose females to increased cardiovascular risk. Several future lines of research are outlined.

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…

Attended and Unattended Automated Office Blood Pressure Measurements Have Better Agreement With Ambulatory Monitoring Than Conventional Office Readings.

PubMed

Andreadis, Emmanuel A; Geladari, Charalampia V; Angelopoulos, Epameinondas T; Savva, Florentia S; Georgantoni, Anna I; Papademetriou, Vasilios

2018-04-07

Automated office blood pressure (AOBP) measurement is superior to conventional office blood pressure (OBP) because it eliminates the "white coat effect" and shows a strong association with ambulatory blood pressure. We conducted a cross-sectional study in 146 participants with office hypertension, and we compared AOBP readings, taken with or without the presence of study personnel, before and after the conventional office readings to determine whether their variation in blood pressure showed a difference in blood pressure values. We also compared AOBP measurements with daytime ambulatory blood pressure monitoring and conventional office readings. The mean age of the studied population was 56±12 years, and 53.4% of participants were male. Bland-Altman analysis revealed a bias (ie, mean of the differences) of 0.6±6 mm Hg systolic for attended AOBP compared with unattended and 1.4±6 and 0.1±6 mm Hg bias for attended compared with unattended systolic AOBP when measurements were performed before and after conventional readings, respectively. A small bias was observed when unattended and attended systolic AOBP measurements were compared with daytime ambulatory blood pressure monitoring (1.3±13 and 0.6±13 mm Hg, respectively). Biases were higher for conventional OBP readings compared with unattended AOBP (-5.6±15 mm Hg for unattended AOBP and oscillometric OBP measured by a physician, -6.8±14 mm Hg for unattended AOBP and oscillometric OBP measured by a nurse, and -2.1±12 mm Hg for unattended AOBP and auscultatory OBP measured by a second physician). Our findings showed that independent of the presence or absence of medical staff, AOBP readings revealed similar values that were closer to daytime ambulatory blood pressure monitoring than conventional office readings, further supporting the use of AOBP in the clinical setting. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Evidence-based management of ambulatory electronic health record system implementation: an assessment of conceptual support and qualitative evidence.

PubMed

McAlearney, Ann Scheck; Hefner, Jennifer L; Sieck, Cynthia; Rizer, Milisa; Huerta, Timothy R

2014-07-01

While electronic health record (EHR) systems have potential to drive improvements in healthcare, a majority of EHR implementations fall short of expectations. Shortcomings in implementations are often due to organizational issues around the implementation process rather than technological problems. Evidence from both the information technology and healthcare management literature can be applied to improve the likelihood of implementation success, but the translation of this evidence into practice has not been widespread. Our objective was to comprehensively study and synthesize best practices for managing ambulatory EHR system implementation in healthcare organizations, highlighting applicable management theories and successful strategies. We held 45 interviews with key informants in six U.S. healthcare organizations purposively selected based on reported success with ambulatory EHR implementation. We also conducted six focus groups comprised of 37 physicians. Interview and focus group transcripts were analyzed using both deductive and inductive methods to answer research questions and explore emergent themes. We suggest that successful management of ambulatory EHR implementation can be guided by the Plan-Do-Study-Act (PDSA) quality improvement (QI) model. While participants did not acknowledge nor emphasize use of this model, we found evidence that successful implementation practices could be framed using the PDSA model. Additionally, successful sites had three strategies in common: 1) use of evidence from published health information technology (HIT) literature emphasizing implementation facilitators; 2) focusing on workflow; and 3) incorporating critical management factors that facilitate implementation. Organizations seeking to improve ambulatory EHR implementation processes can use frameworks such as the PDSA QI model to guide efforts and provide a means to formally accommodate new evidence over time. Implementing formal management strategies and incorporating

Estimating the costs of VA ambulatory care.

PubMed

Phibbs, Ciaran S; Bhandari, Aman; Yu, Wei; Barnett, Paul G

2003-09-01

This article reports how we matched Common Procedure Terminology (CPT) codes with Medicare payment rates and aggregate Veterans Affairs (VA) budget data to estimate the costs of every VA ambulatory encounter. Converting CPT codes to encounter-level costs was more complex than a simple match of Medicare reimbursements to CPT codes. About 40 percent of the CPT codes used in VA, representing about 20 percent of procedures, did not have a Medicare payment rate and required other cost estimates. Reconciling aggregated estimated costs to the VA budget allocations for outpatient care produced final VA cost estimates that were lower than projected Medicare reimbursements. The methods used to estimate costs for encounters could be replicated for other settings. They are potentially useful for any system that does not generate billing data, when CPT codes are simpler to collect than billing data, or when there is a need to standardize cost estimates across data sources.

Ambulatory or home measurement of blood pressure?

PubMed

Gosse, Philippe; Coulon, Paul

2009-04-01

Ambulatory blood pressure monitoring (ABPM) and home blood pressure (HBPM) monitoring have been shown to be superior to conventional measurement of blood pressure in terms of reproducibility, relationship to the impact of high blood pressure on target organs, and the prediction of cardiovascular events. Nevertheless, these 2 techniques have yet to find their place in the diagnosis of hypertension and during evaluation of the efficacy of antihypertensive treatment. Although these 2 methods do not give identical results in approximately 20% of cases, their diagnostic performance and prognostic value are quite comparable. Although ABPM remains a valuable tool in clinical research, its utilization in routine clinical practice is limited by cost and availability. HBPM is increasingly employed for informed and well-managed patients, and it can help to improve control of the patient's blood pressure. Physicians involved in the management of hypertensive patients should be aware of its value in order to assist patients in their care.

76 FR 66931 - Medicare Program: Notice of Two Membership Appointments to the Advisory Panel on Ambulatory...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-28

... Administrator) concerning the clinical integrity of the APC groups and their weights. The advice provided by the Panel will be considered as CMS prepares its annual updates of the hospital outpatient prospective... clinical integrity of the Ambulatory Payment Classification (APC) groups and their associated weights. The...

Effects of health information exchange adoption on ambulatory testing rates

PubMed Central

Ross, Stephen E; Radcliff, Tiffany A; LeBlanc, William G; Dickinson, L Miriam; Libby, Anne M; Nease, Donald E

2013-01-01

Objective To determine the effects of the adoption of ambulatory electronic health information exchange (HIE) on rates of laboratory and radiology testing and allowable charges. Design Claims data from the dominant health plan in Mesa County, Colorado, from 1 April 2005 to 31 December 2010 were matched to HIE adoption data on the provider level. Using mixed effects regression models with the quarter as the unit of analysis, the effect of HIE adoption on testing rates and associated charges was assessed. Results Claims submitted by 306 providers in 69 practices for 34 818 patients were analyzed. The rate of testing per provider was expressed as tests per 1000 patients per quarter. For primary care providers, the rate of laboratory testing increased over the time span (baseline 1041 tests/1000 patients/quarter, increasing by 13.9 each quarter) and shifted downward with HIE adoption (downward shift of 83, p<0.01). A similar effect was found for specialist providers (baseline 718 tests/1000 patients/quarter, increasing by 19.1 each quarter, with HIE adoption associated with a downward shift of 119, p<0.01). Even so, imputed charges for laboratory tests did not shift downward significantly in either provider group, possibly due to the skewed nature of these data. For radiology testing, HIE adoption was not associated with significant changes in rates or imputed charges in either provider group. Conclusions Ambulatory HIE adoption is unlikely to produce significant direct savings through reductions in rates of testing. The economic benefits of HIE may reside instead in other downstream outcomes of better informed, higher quality care. PMID:23698257

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

PubMed

Grasland, A; Mortier, E

2018-04-16

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

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.

Evaluating the implementation of RxNorm in ambulatory electronic prescriptions

PubMed Central

Ward-Charlerie, Stacy; Rupp, Michael T; Kilbourne, John; Amin, Vishal P; Ruiz, Joshua

2016-01-01

Objective RxNorm is a standardized drug nomenclature maintained by the National Library of Medicine that has been recommended as an alternative to the National Drug Code (NDC) terminology for use in electronic prescribing. The objective of this study was to evaluate the implementation of RxNorm in ambulatory care electronic prescriptions (e-prescriptions). Methods We analyzed a random sample of 49 997 e-prescriptions that were received by 7391 locations of a national retail pharmacy chain during a single day in April 2014. The e-prescriptions in the sample were generated by 37 801 ambulatory care prescribers using 519 different e-prescribing software applications. Results We found that 97.9% of e-prescriptions in the study sample could be accurately represented by an RxNorm identifier. However, RxNorm identifiers were actually used as drug identifiers in only 16 433 (33.0%) e-prescriptions. Another 431 (2.5%) e-prescriptions that used RxNorm identifiers had a discrepancy in the corresponding Drug Database Code qualifier field or did not have a qualifier (Term Type) at all. In 10 e-prescriptions (0.06%), the free-text drug description and the RxNorm concept unique identifier pointed to completely different drug concepts, and in 7 e-prescriptions (0.04%), the NDC and RxNorm drug identifiers pointed to completely different drug concepts. Discussion The National Library of Medicine continues to enhance the RxNorm terminology and expand its scope. This study illustrates the need for technology vendors to improve their implementation of RxNorm; doing so will accelerate the adoption of RxNorm as the preferred alternative to using the NDC terminology in e-prescribing. PMID:26510879

Comparison of ambulatory blood pressure parameters of hypertensive patients with and without chronic kidney disease.

PubMed

Mojón, Artemio; Ayala, Diana E; Piñeiro, Luis; Otero, Alfonso; Crespo, Juan J; Moyá, Ana; Bóveda, Julia; de Lis, Jesús Pérez; Fernández, José R; Hermida, Ramón C

2013-03-01

There is strong association between chronic kidney disease (CKD) and increased prevalence of hypertension, risk of end-organ damage, and cardiovascular disease (CVD). Non-dipping, as determined by ambulatory blood pressure (BP) monitoring (ABPM), is frequent in CKD and has also been consistently associated with increased CVD risk. The reported prevalence of non-dipping in CKD is highly variable, probably due to relatively small sample sizes, reliance only on a single, low-reproducibility, 24-h ABPM evaluation per participant, and definition of daytime and nighttime periods by arbitrary fixed clock-hour spans. Accordingly, we assessed the circadian BP pattern of patients with and without CKD by 48-h ABPM to increase reproducibility of the results. This cross-sectional study involved 10 271 hypertensive patients (5506 men/4765 women), 58.0 ± 14.2 (mean ± SD) yrs of age, enrolled in the Hygia Project. Among the participants, 3227 (1925 men/1302 women) had CKD. At the time of recruitment, 568/2234 patients with/without CKD were untreated for hypertension. Patients with than without CKD were more likely to be men and of older age, have diagnoses of obstructive sleep apnea, metabolic syndrome, diabetes, and/or obesity, plus have higher glucose, creatinine, uric acid, and triglyceride, but lower cholesterol, concentrations. In patients with CKD, ambulatory systolic BP (SBP) was significantly elevated (p < .001), mainly during the hours of nighttime sleep, independent of presence/absence of BP-lowering treatment. In patients without CKD, ambulatory diastolic BP (DBP), however, was significantly higher (p < .001), mainly during the daytime. Differing trends for SBP and DBP between groups resulted in large differences in ambulatory pulse pressure (PP), it being significantly greater (p < .001) for the entire 24 h in patients with CKD. Prevalence of non-dipping was significantly higher in patients with than without CKD (60.6% vs. 43.2%; p < .001

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

Low-complexity R-peak detection in ECG signals: a preliminary step towards ambulatory fetal monitoring.

PubMed

Rooijakkers, Michiel; Rabotti, Chiara; Bennebroek, Martijn; van Meerbergen, Jef; Mischi, Massimo

2011-01-01

Non-invasive fetal health monitoring during pregnancy has become increasingly important. Recent advances in signal processing technology have enabled fetal monitoring during pregnancy, using abdominal ECG recordings. Ubiquitous ambulatory monitoring for continuous fetal health measurement is however still unfeasible due to the computational complexity of noise robust solutions. In this paper an ECG R-peak detection algorithm for ambulatory R-peak detection is proposed, as part of a fetal ECG detection algorithm. The proposed algorithm is optimized to reduce computational complexity, while increasing the R-peak detection quality compared to existing R-peak detection schemes. Validation of the algorithm is performed on two manually annotated datasets, the MIT/BIH Arrhythmia database and an in-house abdominal database. Both R-peak detection quality and computational complexity are compared to state-of-the-art algorithms as described in the literature. With a detection error rate of 0.22% and 0.12% on the MIT/BIH Arrhythmia and in-house databases, respectively, the quality of the proposed algorithm is comparable to the best state-of-the-art algorithms, at a reduced computational complexity.

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.

HMO Penetration, Hospital Competition, and Growth of Ambulatory Surgery Centers

PubMed Central

Bian, John; Morrisey, Michael A.

2006-01-01

Using metropolitan statistical area (MSA) panel data from 1992-2001 constructed from the 2002 Medicare Online Survey Certification and Reporting (OSCAR) System, we estimate the market effects of health maintenance organization (HMO) penetration and hospital competition on the growth of freestanding ambulatory surgery centers (ASCs). Our regression models with MSA and year fixed effects suggest that a 10-percentage-point increase in HMO penetration is associated with a decrease of 3 ASCs per 1 million population. A decrease from 5 to 4 equal-market-shared hospitals in a market is associated with an increase of 2.5 ASCs per 1 million population. PMID:17290661

Ambulatory blood pressure and heart rate in paramedics: effects of cynical hostility and defensiveness.

PubMed

Jamner, L D; Shapiro, D; Goldstein, I B; Hug, R

1991-01-01

Ambulatory blood pressure and heart rate responses were obtained in 33 male paramedics during a 24-hour work shift to examine the effects of episodes of occupational stress on cardiovascular reactivity and subjective reports of stress. The aim of this study was to determine how individual differences in cynical hostility and defensiveness interacted with situational demands to affect cardiovascular responses in a natural setting. Defensiveness was found to interact significantly with cynical hostility in predicting subjects' heart rate responses in different work contexts. Specifically, in a hospital setting involving interpersonal conflict, subjects who were high in both defensiveness and hostility showed heart rate responses approximately 10 bpm higher than subjects who were high in hostility but low in defensiveness. The same pattern of relationships was obtained for diastolic blood pressure. High and low hostile subjects were also found to differ from each other in their daily mean levels of ambulatory blood pressure during awake and sleep periods. These findings obtained in a natural setting lend further support to the significance of cynical hostility for cardiovascular reactivity. The results for defensiveness suggest the need for further research on the role of conflicting attitudes in the pathophysiology of cardiovascular diseases.

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

PubMed

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

2013-01-01

To estimate the sensitivity, specificity and positive and negative predictive values of the Unified Health System's Hospital Information System for the appropriate recording of hospitalizations for ambulatory care-sensitive conditions. The hospital information system records for conditions which are sensitive to ambulatory care, and for those which are not, were considered for analysis, taking the medical records as the gold standard. Through simple random sampling, a sample of 816 medical records was defined and selected by means of a list of random numbers using the Statistical Package for Social Sciences. The sensitivity was 81.89%, specificity was 95.19%, the positive predictive value was 77.61% and the negative predictive value was 96.27%. In the study setting, the Hospital Information System (SIH) was more specific than sensitive, with nearly 20% of care sensitive conditions not detected. There are no validation studies in Brazil of the Hospital Information System records for the hospitalizations which are sensitive to primary health care. These results are relevant when one considers that this system is one of the bases for assessment of the effectiveness of primary health care.

The effect of continuous nursing intervention guided by chronotherapeutics on ambulatory blood pressure of older hypertensive patients in the community.

PubMed

Cheng, Mei; Cheng, Shu-Ling; Zhang, Qing; Jiang, He; Cong, Ji-Yan; Zang, Xiao-Ying; Zhao, Yue

2014-08-01

To explore the effect of continuous nursing intervention guided by chronotherapeutics so as to provide the easy, noninvasive, effective and acceptable intervention for older hypertensive patients in the community. Many researchers studied the effect of administration at different times on blood pressure control and circadian rhythm. However, the individual administrative time was set ambiguously in previous studies. A semi-experimental study. In the study, 90 eligible patients were recruited and separated into three groups randomly, which were the control group, intervention group A (behaviour and chronotherapy intervention) and intervention group B (behaviour intervention). At 6 and 12 months after the study, the intervention groups were measured 24-hour ambulatory blood pressure monitoring. There were significant differences in ambulatory blood pressure monitoring parameters of the two intervention groups at different measurement times, and there were interaction between measurement time and different groups. The number of patients with dipper increased and reverse dipper decreased in group A as the intervention applied. There were statistical differences between two groups. The number of patients with morning surge in group A decreased more, and there were statistical differences between two groups at six months after the intervention. The behaviour and chronotherapy intervention based on the patients' ambulatory blood pressure monitoring can control casual blood pressure much better and last longer, which can also improve patients' indexes of ambulatory blood pressure monitoring better than behaviour intervention only. The behaviour and chronotherapy intervention can increase patients' nocturnal blood pressure drop, increase the number of patients with dipper and decrease reverse dipper, and improve blood pressure surge in the morning. Nurses can use continuous nursing intervention guided by chronotherapeutics to help improve hypertension of older patients

The Role of Ambulatory Assessment in Psychological Science.

PubMed

Trull, Timothy J; Ebner-Priemer, Ulrich

2014-12-01

We describe the current use and future promise of an innovative methodology, ambulatory assessment (AA), that can be used to investigate psychological, emotional, behavioral, and biological processes of individuals in their daily life. The term AA encompasses a wide range of methods used to study people in their natural environment, including momentary self-report, observational, and physiological. We emphasize applications of AA that integrate two or more of these methods, discuss the smart phone as a hub or access point for AA, and discuss future applications of AA methodology to the science of psychology. We pay particular attention to the development and application of Wireless Body Area Networks (WBANs) that can be implemented with smart phones and wireless physiological monitoring devices, and we close by discussing future applications of this approach to matters relevant to psychological science.

A Prospective Study in Comparison of Ambulatory Phlebectomy and Duplex Guided Foam Sclerotherapy in the Management of Varicosities with Isolated Perforator Incompetence.

PubMed

Kishore, R; Sankar, T Bavani; Anandi, A; Nedunchezhian, S; Murugan, Valarmathy

2016-10-01

Perforators are those which connect the superficial and deep venous system either directly to main veins or indirectly through the muscular and soleal venous plexus. The emergence of minimally invasive techniques like ambulatory phlebectomy (AP) and foam sclerotherapy (FS) has led to increasing interest about the appropriate therapy for the treatment of isolated perforator incompetence. There have been no studies which have compared the effectiveness of these in-office procedures in isolated perforator incompetence due to the low prevalence of cases. The primary goal of this study is to compare the clinical parameters (return to normal activity, primary symptom relief), functional parameters (procedure time, change in disease severity, course of venous ulcer), and duplex parameters (recurrence in treated veins, complete occlusion of treated veins) in the management of leg varicosities having isolated primary perforator incompetence by ambulatory phlebectomy and duplex guided foam sclerotherapy. Though the procedure time was shorter with FS than AP, the other parameters of primary symptom relief such as change in disease severity, faster healing of venous ulcer, complete occlusion of treated veins in follow-up duplex examination, and lower recurrence of treated veins are better with AP than FS. In conclusion, the interruption of perforators is effective in decreasing the symptoms of chronic venous insufficiency and for the rapid healing of ulcers. The interruption of the incompetent perforating veins appears to be essential to decrease ambulatory venous hypertension. It is apparent from this study that ambulatory phlebectomy stands distinct with enormous benefits and serves as a superior alternative to foam sclerotherapy in treating patients with isolated perforator incompetence.

Renal denervation reduces office and ambulatory heart rate in patients with uncontrolled hypertension: 12-month outcomes from the global SYMPLICITY registry.

PubMed

Böhm, Michael; Ukena, Christian; Ewen, Sebastian; Linz, Dominik; Zivanovic, Ina; Hoppe, Uta; Narkiewicz, Krzysztof; Ruilope, Luis; Schlaich, Markus; Negoita, Manuela; Schmieder, Roland; Williams, Bryan; Zeymer, Uwe; Zirlik, Andreas; Mancia, Giuseppe; Mahfoud, Felix

2016-12-01

Renal denervation (RDN) can reduce sympathetic activity and blood pressure (BP) in patients with hypertension. The effects on resting and ambulatory heart rate (HR), also regulated by the sympathetic nervous system, are not established. Herein, we report 12-month outcomes from the Global SYMPLICITY Registry on office and ambulatory HR and BP in patients with uncontrolled hypertension (n = 846). HR declined in correlation with the HR at baseline and at 12 months, in particular, in patients in the upper tertile of HR (>74 bpm). BP reduction was similar in the tertiles of HR at baseline. Similar effects were observed when 24-h ambulatory HR and SBP were determined. Office HR was similarly decreased when patients were on a β-blocker or not. Antihypertensive treatment remained unchanged during the 12-month period of the Global SYMPLICITY Registry. RDN reduces BP independent from HR. A HR reduction is dependent on baseline HR and unchanged by β-blocker treatment. The effects of RDN on SBP and HR are durable up to 1 year. HR reduction might be a target for RDN in patients with high HR at baseline, which needs to be scrutinized in prospective trials.

Incorporating assessment and prescribing for ambulatory ailments skills into practice: An environmental scan of continuing education for pharmacist prescribing in Canada.

PubMed

Habicht, Dana; Ng, Sheila; Dunford, Drena; Shearer, Brenna; Kuo, I Fan

2017-01-01

Pharmacists in Canadian provinces are at different stages of applying prescribing legislation into practice. The purpose of this environmental scan was to examine differences in legislation, remuneration, professional uptake, continuing education requirements and continuing education resources relating to pharmacist prescribing for ambulatory ailments, with a focus on continuing education. Data were collected between May and December 2016 using websites and communication with provincial professional regulatory bodies, advocacy bodies, drug coverage programs and other organizations that offer continuing education for pharmacists. Training requirements to prescribe for ambulatory ailments vary provincially, including no training requirements, online tutorials and a comprehensive application process. Government-funded remuneration for prescribing services is absent in most provinces. Pharmacist uptake of the training required to obtain prescribing authority ranges from 30% to 100% of pharmacists. Continuing education programs on the topic of prescribing across the country include online courses, in-person courses, webinars, panel discussions and preparation courses. Many aspects of pharmacist prescribing for ambulatory ailments, including the style and content of continuing education resources, vary from province to province. Further research on this topic would help to determine the effect of these differences on the success of incorporating pharmacist prescribing into practice.

Muscle Strength Enhancement Following Home-Based Virtual Cycling Training in Ambulatory Children with Cerebral Palsy

ERIC Educational Resources Information Center

Chen, Chia-Ling; Hong, Wei-Hsien; Cheng, Hsin-Yi Kathy; Liaw, Mei-Yun; Chung, Chia-Ying; Chen, Chung-Yao

2012-01-01

This study is the first well-designed randomized controlled trial to assess the effects of a novel home-based virtual cycling training (hVCT) program for improving muscle strength in children with spastic cerebral palsy (CP). Twenty-eight ambulatory children with spastic CP aged 6-12 years were randomly assigned to an hVCT group (n = 13) or a…

Neighborhood blight, stress, and health: a walking trial of urban greening and ambulatory heart rate

Treesearch

Eugenia C. South; Michelle C. Kondo; Rose A. Cheney; Charles C. Branas

2015-01-01

We measured dynamic stress responses using ambulatory heart rate monitoring as participants in Philadelphia, Pennsylvania walked past vacant lots before and after a greening remediation treatment of randomly selected lots. Being in view of a greened vacant lot decreased heart rate significantly more than did being in view of a nongreened vacant lot or not in view of...

The effect of complementary therapies on post-operative pain control in ambulatory knee surgery: a systematic review.

PubMed

Barlow, Timothy; Downham, Christopher; Barlow, David

2013-10-01

Ambulatory knee surgery is a common procedure with over 100,000 knee arthroscopies performed in the U.K. in 2010-2011. Pain after surgery can decrease patient satisfaction, delay discharge, and decrease cost effectiveness. Multi-modal therapies, including complementary therapies, to improve pain control after surgery have been recommended. However, a comprehensive review of the literature regarding the use of complementary therapies to enhance pain control after ambulatory knee surgery is lacking, and this article aims to address this deficit. CINHAL, EMBASE, MEDLINE, AMED and CENTRAL databases were searched. Only Randomised Controlled Trials were included. All eligible papers were quality assessed using the Jadad system, and data was extracted using piloted forms. Two independent reviewers performed each stage of the review. Full details of the study methodology can be found on Prospero, a systematic review register. Five studies satisfied our eligibility criteria: three reporting on acupuncture, one on homeopathy, and one on acupoints. Acupoint pressure was the only study that demonstrated reduced pain compared with placebo. This study was the least methodologically robust. Arnica, although demonstrating a significant reduction in swelling, did not affect post-operative pain. Acupuncture did not affect post-operative pain; however, a reduction in ibuprofen use was demonstrated in two studies. Before recommending complementary therapy for routine use in ambulatory knee surgery, further work is required. Two areas of future research likely to bear fruit are demonstrating robust evidence for the effect of acupoint pressure on post-operative pain, and quantifying the positive effect of homeopathic arnica on post-operative swelling. Copyright © 2013 Elsevier Ltd. All rights reserved.

INtensive versus Standard Ambulatory Blood Pressure Lowering to Prevent Functional DeclINe In The ElderlY (INFINITY)

PubMed Central

White, William B.; Marfatia, Ravi; Schmidt, Julia; Wakefield, Dorothy B.; Kaplan, Richard F.; Bohannon, Richard W.; Hall, Charles B.; Guttmann, Charles R.; Moscufo, Nicola; Fellows, Douglas; Wolfson, Leslie

2012-01-01

Reductions in mobility and cognitive function linked to accrual of brain microvascular disease related white-matter hyperintensities(WMH) on magnetic resonance imaging (MRI) canoccur in older hypertensive patients in as little as 2 years. We have designed a trial evaluating two levels of ambulatory BP control in individuals with normal or mildly impaired mobility and cognition who have detectable cerebrovascular disease (>0.5% WMH fraction of intracranial volume) on functional outcomes. The study is a prospective randomized, open-label trial with blinded endpoints, inpatients ages 75 and older with elevated 24-h systolic BP (≥145 mmHg in the untreated state) who do not have unstable cardiovascular disease, heart failure or stroke. The primary and key secondary outcomes in the trial are: change from baseline in mobility and cognitive function and damage to brain white matter as demonstrated by accrual of WMH volume and changes indiffusion tensor imaging.Approximately 300 patients will be enrolled and 200 randomized to one of two levels of ambulatory BP control (intensive to achieve a goal 24-hour systolic BP of ≤ 130 mmHg or standard to achieve a goal 24-hour systolic BP of ≤ 145 mmHg) for a total of 36 months using similar antihypertensive regimens. The analytical approach provides 85% power to show a clinically meaningful effect in differences in mobility accompanied by quantitative differences in WMH between treatment groups. The INFINITY trial is the first to guide antihypertensive therapy using ambulatory BP monitoring rather than clinic BP to reduce cerebrovascular disease. PMID:23453090

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 and...

Effects of laparotomy vs pneumoperitoneum on the hepatic catabolic stress response in ambulatory and stationary settings in pigs.

PubMed

Lausten, S B; Grøfte, T; Andreasen, F; Vilstrup, H; Jensen, S L

1999-04-01

We recently demonstrated that laparoscopic cholecystectomy is followed by a much smaller hepatic catabolic stress response than conventional cholecystectomy. It is not known what is responsible for this difference. Thirty pigs were randomly allocated to the following five treatment groups: (1) laparotomy, (2) pneumoperitoneum, (3) pneumoperitoneum with insertion of four trocars, (4) laparotomy, (5) pneumoperitoneum. Groups 1-3 were operated on in an ambulatory setting, whereas groups 4 and 5 were operated on in a stationary setting. Urea synthesis, as quantified by functional hepatic nitrogen clearance, and the response of stress hormones and cytokines were assessed. Laparotomy increased the functional hepatic nitrogen clearance by 195% (p < 0.001); pneumoperitoneum and trocars increased it by 145% (p < 0.001); and pneumoperitoneum alone increased it by 113% (p < 0. 001). The difference between laparotomy and both pneumoperitoneum groups was significant. If the stress factor of ambulatory surgery was eliminated, the increase in functional hepatic nitrogen clearance was reduced to 87% (p < 0.01) after laparotomy and 38% (NS) for animals subject to pneumoperitoneum. There were significant differences in concentrations of stress hormones, tumor necrosis factor alpha, and interleukin 8 among groups intra- and postoperatively. The magnitude of the postoperative hepatic stress response after laparotomy compared to pneumoperitoneum with and without insertion of trocars seems to be caused by the greater trauma to the abdominal wall. Furthermore, an ambulatory setting seems to be an important postoperative stress factor in itself.

Effect of physician ownership of specialty hospitals and ambulatory surgery centers on frequency of use of outpatient orthopedic surgery.

PubMed

Mitchell, Jean M

2010-08-01

Physician-owned specialty hospitals and ambulatory surgery centers have become commonplace in many markets throughout the United States. Little is known about whether the financial incentives linked to ownership affect frequency of outpatient surgery. To evaluate if financial incentives linked to physician ownership influence frequency of outpatient orthopedic surgical procedures. We analyzed 5 years of claims data from a large private insurer in Idaho to compare frequency by orthopedic surgeon owners and nonowners of surgical procedures that could be performed in either ambulatory surgery centers or hospital outpatient surgery departments. Frequency of use, calculated as number of patients treated with the specific diagnoses who received the surgical procedure of interest divided by the number of patients with such diagnoses treated by each physician. Age- and sex-adjusted odds ratios indicate that the likelihood of having carpal tunnel repair was 54% to 129% higher for patients of surgeon owners compared with surgeon nonowners. For rotator cuff repair, the adjusted odds ratios of having surgery were 33% to 100% higher for patients treated by physician owners. The age- and sex-adjusted probability of arthroscopic surgery was 27% to 78% higher for patients of surgeon owners compared with surgeon nonowners. The consistent finding of higher use rates by physician owners across time clearly suggests that financial incentives linked to ownership of either specialty hospitals or ambulatory surgery centers influence physicians' practice patterns.

Assessing technical performance at diverse ambulatory care sites.

PubMed

Osterweis, M; Bryant, E

1978-01-01

The purpose of the large study reported here was to develop and test methods for assessing the quality of health care that would be broadly applicable to diverse ambulatory care organizations for periodic comparative review. Methodological features included the use of an age-sex stratified random sampling scheme, dependence on medical records as the source of data, a fixed study period year, use of Kessner's tracer methodology (including not only acute and chronic diseases but also screening and immunization rates as indicators), and a fixed tracer matrix at all test sites. This combination of methods proved more efficacious in estimating certain parameters for the total patient populations at each site (including utilization patterns, screening, and immunization rates) and the process of care for acute conditions than it did in examining the process of care for the selected chronic condition. It was found that the actual process of care at all three sites for the three acute conditions (streptococcal pharyngitis, urinary tract infection, and iron deficiency anemia) often differed from the expected process in terms of both diagnostic procedures and treatment. For hypertension, the chronic disease tracer, medical records were frequently a deficient data source from which to draw conclusions about the adequacy of treatment. Several aspects of the study methodology were found to be detrimental to between-site comparisons of the process of care for chronic disease management. The use of an age-sex stratified random sampling scheme resulted in the identification of too few cases of hypertension at some sites for analytic purposes, thereby necessitating supplementary sampling by diagnosis. The use of a fixed study period year resulted in an arbitrary starting point in the course of the disease. Furthermore, in light of the diverse sociodemographic characteristics of the patient populations, the use of a fixed matrix of tracer conditions for all test sites is questionable

Development of quality metrics for ambulatory pediatric cardiology: Infection prevention.

PubMed

Johnson, Jonathan N; Barrett, Cindy S; Franklin, Wayne H; Graham, Eric M; Halnon, Nancy J; Hattendorf, Brandy A; Krawczeski, Catherine D; McGovern, James J; O'Connor, Matthew J; Schultz, Amy H; Vinocur, Jeffrey M; Chowdhury, Devyani; Anderson, Jeffrey B

2017-12-01

In 2012, the American College of Cardiology's (ACC) Adult Congenital and Pediatric Cardiology Council established a program to develop quality metrics to guide ambulatory practices for pediatric cardiology. The council chose five areas on which to focus their efforts; chest pain, Kawasaki Disease, tetralogy of Fallot, transposition of the great arteries after arterial switch, and infection prevention. Here, we sought to describe the process, evaluation, and results of the Infection Prevention Committee's metric design process. The infection prevention metrics team consisted of 12 members from 11 institutions in North America. The group agreed to work on specific infection prevention topics including antibiotic prophylaxis for endocarditis, rheumatic fever, and asplenia/hyposplenism; influenza vaccination and respiratory syncytial virus prophylaxis (palivizumab); preoperative methods to reduce intraoperative infections; vaccinations after cardiopulmonary bypass; hand hygiene; and testing to identify splenic function in patients with heterotaxy. An extensive literature review was performed. When available, previously published guidelines were used fully in determining metrics. The committee chose eight metrics to submit to the ACC Quality Metric Expert Panel for review. Ultimately, metrics regarding hand hygiene and influenza vaccination recommendation for patients did not pass the RAND analysis. Both endocarditis prophylaxis metrics and the RSV/palivizumab metric passed the RAND analysis but fell out during the open comment period. Three metrics passed all analyses, including those for antibiotic prophylaxis in patients with heterotaxy/asplenia, for influenza vaccination compliance in healthcare personnel, and for adherence to recommended regimens of secondary prevention of rheumatic fever. The lack of convincing data to guide quality improvement initiatives in pediatric cardiology is widespread, particularly in infection prevention. Despite this, three metrics were

Impact of Stress Reduction Interventions on Hostility and Ambulatory Systolic Blood Pressure in African American Adolescents

ERIC Educational Resources Information Center

Wright, Lynda Brown; Gregoski, Mathew J.; Tingen, Martha S.; Barnes, Vernon A.; Treiber, Frank A.

2011-01-01

This study examined the impact of breathing awareness meditation (BAM), life skills (LS) training, and health education (HE) interventions on self-reported hostility and 24-hour ambulatory blood pressure (ABP) in 121 African American (AA) ninth graders at increased risk for development of essential hypertension. They were randomly assigned to BAM,…

Cough in Ambulatory Immunocompromised Adults: CHEST Expert Panel Report.

PubMed

Rosen, Mark J; Ireland, Belinda; Narasimhan, Mangala; French, Cynthia; Irwin, Richard S

2017-11-01

Cough is a common symptom prompting patients to seek medical care. Like patients in the general population, patients with compromised immune systems also seek care for cough. However, it is unclear whether the causes of cough in immunocompromised patients who are deemed unlikely to have a life-threating condition and a normal or unchanged chest radiograph are similar to those in persons with cough and normal immune systems. We conducted a systematic review to answer the question: What are the most common causes of cough in ambulatory immunodeficient adults with normal chest radiographs? Studies of patients ≥ 18 years of age with immune deficiency, cough of any duration, and normal or unchanged chest radiographs were included and assessed for relevance and quality. Based on the systematic review, suggestions were developed and voted on using the American College of Chest Physicians (CHEST) methodology framework. The results of the systematic review revealed no high-quality evidence to guide the clinician in determining the likely causes of cough specifically in immunocompromised ambulatory patients with normal chest radiographs. Based on a systematic review, we found no evidence to assess whether or not the proper initial evaluation of cough in immunocompromised patients is different from that in immunocompetent persons. A consensus of the panel suggested that the initial diagnostic algorithm should be similar to that for immunocompetent persons but that the context of the type and severity of the immune defect, geographic location, and social determinants be considered. The major modifications to the 2006 CHEST Cough Guidelines are the suggestions that TB should be part of the initial evaluation of patients with cough and HIV infection who reside in regions with a high prevalence of TB, regardless of the radiographic findings, and that specific causes and immune defects be considered in all patients in whom the initial evaluation is unrevealing. Copyright �

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.

Severity of illness and ambulatory care-sensitive conditions.

PubMed

Yuen, Elaine J

2004-09-01

This study describes how severity of illness may refine the definition of ambulatory care-sensitive conditions, or ACSCs. Hospital discharge abstract data from Philadelphia were combined with census data to develop population-based adjusted rates of hospitalization for diabetes and asthma, two ACSCs. By stratifying ACSC hospitalization by severity of illness, variations were observed by age, race, and gender. Minority groups may be at higher risk for less access to outpatient primary care and were observed to have higher rates of more severely ill, Stage 3 hospitalization. Geographic map displays indicated wide ranges of age-sex-adjusted rates for high-severity hospitalization in the five-county Philadelphia region. This refined ACSC measure may help to identify specific groups and clinical conditions within a population to assist health care planners estimate health care resources such as facilities, manpower, and programs, as well as to evaluate their outcomes.

The Ambulatory and Home Care Record: A Methodological Framework for Economic Analyses in End-of-Life Care

PubMed Central

Guerriere, Denise N.; Coyte, Peter C.

2011-01-01

Provision of end-of-life care in North America takes place across a multitude of settings, including hospitals, ambulatory clinics and home settings. As a result, family caregiving is characteristically a major component of care within the home. Accordingly, economic evaluation of the end-of-life care environment must devote equal consideration to resources provided by the public health system as well as privately financed resources, such as time and money provided by family caregivers. This paper addresses the methods used to measure end-of-life care costs. The existing empirical literature will be reviewed in order to assess care costs with areas neglected in this body of literature to be identified. The Ambulatory and Home Care Record, a framework and tool for comprehensively measuring costs related to the provision and receipt of end-of-life care across all health care settings, will be described and proposed. Finally, areas for future work will be identified, along with their potential contribution to this body of knowledge. PMID:21629752

Use of risk stratification to guide ambulatory management of neutropenic fever. Australian Consensus Guidelines 2011 Steering Committee.

PubMed

Worth, L J; Lingaratnam, S; Taylor, A; Hayward, A M; Morrissey, S; Cooney, J; Bastick, P A; Eek, R W; Wei, A; Thursky, K A

2011-01-01

Utilization of risk-stratification tools in the setting of neutropenic fever is currently limited by inadequate knowledge and lack of awareness. Within this context, the approach to management of low-risk patients with neutropenic fever is inconsistent with the available evidence across many Australian treating centres. These clinical guidelines define and clarify an accepted standard of care for this patient group given the current evidence base. The Multinational Association for Supportive Care in Cancer risk index is presented as the preferred risk assessment tool for determining patient risk. Suitability of ambulatory care within specific patient populations is discussed, with defined eligibility criteria provided to guide clinical decision-making. Detailed recommendations for implementing appropriate ambulatory strategies, such as early discharge and outpatient antibiotic therapy, are also provided. Due consideration is given to infrastructural requirements and other supportive measures at a resourcing and operational level. An analysis of the relevant health economics is also presented. © 2011 The Authors. Internal Medicine Journal © 2011 Royal Australasian College of Physicians.

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.

Reductions in ambulatory blood pressure in young normotensive men and women after isometric resistance training and its relationship with cardiovascular reactivity.

PubMed

Somani, Yasina; Baross, Anthony; Levy, Phillip; Zinszer, Kate; Milne, Kevin; Swaine, Ian; McGowan, Cheri

2017-02-01

There has been very little published work exploring the comparative effects of isometric resistance training (IRT) on blood pressure (BP) in men and women. Most of the previously published work has involved men and used resting BP as the primary outcome variable. Early evidence suggests that IRT is particularly effective in older women and has a positive influence on ambulatory BP, a better predictor of disease risk. With the WHO now placing global emphasis on the primary prevention of hypertension, the goals of this proof-of-concept study were to (i) examine whether sex differences exist in the ambulatory BP-lowering effects of IRT in young, normotensive men and women and (ii) determine whether these reductions can be predicted by simple laboratory stress tasks (a 2-min sustained isometric contraction and a math task involving subtracting a two-digit number from a series of numbers). There were no differences in the IRT-induced reductions in 24-h (men: Δ4 mmHg, women: Δ4 mmHg), daytime (men: Δ3 mmHg, women: Δ4 mmHg), or night-time (men: Δ4 mmHg, women: Δ3 mmHg) ambulatory BP in men (n=13) and women (n=11) (P<0.05) and these changes were not associated with systolic BP reactivity to either stress task (all P>0.05). Our data suggest that lower ambulatory BP can be achieved, to a similar magnitude in young healthy women as well as men, with IRT; however, the BP-lowering effectiveness cannot be predicted by systolic BP reactivity. Taken together, this work heralds a potentially novel approach to the primary prevention of hypertension in both men and women and warrants further investigation in a larger clinical outcome trial.

Changing the paradigm: planning for ambulatory care expansion in Los Angeles County using a community-based and evidence-based model.

PubMed

Fielding, J E; Lamirault, I; Nolan, B; Bobrowsky, J

2000-07-01

In 1998, Los Angeles County's Department of Health Services (DHS) embarked on a planning process to expand ambulatory care services for the county's 2.7 million uninsured and otherwise medically indigent residents. This planning process was novel in two ways. First, it used a quantitative, needs-based approach for resource allocation to ensure an equitable distribution of safety-net ambulatory care services across the county. Second, it used a new community-based planning paradigm that took into consideration the specific needs of each of the county's eight geographic service planning areas. Together, the evidence-based approach to planning and the community-based decision-making will ensure that DHS can more equitably provide for the needs of Los Angeles County's medically indigent residents.

Racism and ambulatory blood pressure in a community sample.

PubMed

Brondolo, Elizabeth; Libby, Daniel J; Denton, Ellen-Ge; Thompson, Shola; Beatty, Danielle L; Schwartz, Joseph; Sweeney, Monica; Tobin, Jonathan N; Cassells, Andrea; Pickering, Thomas G; Gerin, William

2008-01-01

Racism has been identified as a psychosocial stressor that may contribute to disparities in the prevalence of cardiovascular disease. The goal of the present article was to investigate the relationship of perceived racism to ambulatory blood pressure (ABP) in a sample of American-born Blacks and Latinos. Participants included English-speaking Black or Latino(a) adults between the ages of 24 and 65. They completed daily mood diaries and measures of perceived racism, socioeconomic status, and hostility. Participants were outfitted with ABP monitors; 357 provided data on waking hours only, and 245 provided data on both waking and nocturnal ABP. Perceived racism was positively associated with nocturnal ABP even when controlling for personality factors and socioeconomic status. The results suggest that racism may influence cardiovascular disease risk through its effects on nocturnal BP recovery.

24-Hour ambulatory blood pressure response to combination valsartan/hydrochlorothiazide and amlodipine/hydrochlorothiazide in stage 2 hypertension by ethnicity: the EVALUATE study.

PubMed

Wright, Jackson T; Lacourcière, Yves; Samuel, Rita; Zappe, Dion; Purkayastha, Das; Black, Henry R

2010-11-01

Several studies reported racial/ethnic differences in blood pressure (BP) response to antihypertensive monotherapy. In a 10-week study of stage 2 hypertension, 320/25 mg valsartan/hydrochlorothiazide (HCTZ) reduced ambulatory BP (ABP) significantly more effectively than 10/25 mg amlodipine/HCTZ. Results (post hoc analysis) are described in Caucasians (n=256), African Americans (n=79), and Hispanics (n=86). Compared with clinic-measured BP (no significant treatment-group differences in ethnic subgroups), least-squares mean reductions from baseline to week 10 in mean ambulatory systolic BP (MASBP) and mean ambulatory diastolic BP (MADBP) favored valsartan/HCTZ over amlodipine/HCTZ in Caucasians (-21.9/-12.7 mm Hg vs -17.6/-9.5 mm Hg; P=.0004/P<.0001). No treatment-group differences in MASBP/MADBP were observed in African Americans (-17.3/-10.6 vs -17.9/-9.5; P=.76/P=.40) or Hispanics (-17.9/-9.7 vs -14.2/-7.2; P=.20/P=.17). Based on ABP monitoring, valsartan/HCTZ is more effective than amlodipine/HCTZ in lowering ABP in Caucasians. In African Americans and Hispanics, both regimens are similarly effective. © 2010 Wiley Periodicals, Inc.

The Treatment of Smoking by US Physicians During Ambulatory Visits: 1994–2003

PubMed Central

Thorndike, Anne N.; Regan, Susan; Rigotti, Nancy A.

2007-01-01

Objectives. We sought to determine whether US physicians’ practice patterns in treating tobacco use at ambulatory visits improved over the past decade with the appearance of national clinical practice guidelines, new smoking cessation medications, and public reporting of physician performance in counseling smokers. Methods. We compared data from the National Ambulatory Medical Care Survey, an annual survey of a random sample of office visits to US physicians, between 1994–1996 and 2001–2003. Results. Physicians identified patients’ smoking status at 68% of visits in 2001–2003 versus 65% in 1994–1996 (adjusted odds ratio [AOR]=1.16; 95% confidence interval [CI]=1.04, 1.30). Physicians counseled about smoking at 20% of smokers’ visits in 2001–2003 versus 22% in 1994–1996 (AOR=0.84; 95% CI=0.71, 0.99). In both time periods, smoking cessation medication use was low (<2% of smokers’ visits) and visits with counseling for smoking were longer than those without such counseling (P<.005). Conclusions. In the past decade, there has been a small increase in physicians’ rates of patients’ smoking status identification and a small decrease in rates of counseling smokers. This lack of progress may reflect barriers in the US health care environment, including limited physician time to provide counseling. PMID:17761570

Medication discrepancies associated with subsequent pharmacist-performed medication reconciliations in an ambulatory clinic.

PubMed

Philbrick, Ann M; Harris, Ila M; Schommer, Jon C; Fallert, Christopher J

2015-01-01

To describe the number of medication discrepancies associated with subsequent medication reconciliations by a clinical pharmacist in an ambulatory family medicine clinic and the proportion of subsequent medication reconciliation visits that were associated with hospital discharge, long-term anticoagulation management, or both. Data on medication reconciliations were collected over a 2-year time period in an ambulatory family medicine clinic for patients taking 10 or more medications. Medication reconciliation was performed 752 times for 500 patients. A total of 5,046 discrepancies were identified, with more than one-half deemed clinically important. A mean (± SD) of 6.7 ± 4.6 discrepancies per visit (3.5 ± 3.2 clinically important) were identified. The findings showed that the distribution of total discrepancies identified by pharmacist-performed medication reconciliation was significantly different over the course of subsequent medication reconciliations. However, the distribution of clinically important discrepancies was not significantly different; important discrepancies were as likely to be found in later reconciliations as in earlier ones. As subsequent medication reconciliation visits were performed, an increasing proportion consisted of post-hospital discharge visits, long-term anticoagulation managed by a clinical pharmacist, or both. Patients with a recent hospital discharge, on long-term anticoagulation management, or both, were more likely to have multiple sessions with a clinical pharmacist for medication reconciliation. These findings can help identify patients for whom medication reconciliation is warranted.

CODEMamb - an observational communication behavior assessment tool for use in ambulatory dementia care.

PubMed

Knebel, Maren; Haberstroh, Julia; Kümmel, Anne; Pantel, Johannes; Schröder, Johannes

2016-12-01

Communication improves well-being and quality of life for both people with dementia and their professional and family caregivers. Individualized communication, as required in informed consent procedures and psychosocial interventions, can improve quality of life, especially in ambulatory settings. However, few valid and reliable instruments exist that enable communication to be assessed and communication and behavioral resources to be identified. We, therefore, extended and adapted the newly developed observational instrument CODEM for use in ambulatory settings (CODEM amb ). Reliability and validity of the new instrument were studied in a total of 171 patients, whereby principal component analysis revealed three important factors: relationship aspects, verbal communication behavior and nonverbal communication behavior. CODEM amb [Formula: see text]s internal consistency, interrater and retest reliability were satisfactory to excellent. Convergent validity indices, as shown by examining correlations with similar but not identical constructs (CERAD-NP verbal subscales), were medium-high, while the divergent validity index (constructional praxis) was relatively low. The relationship to peer-rating remained nonsignificant. Criterion validity was investigated in groups of patients in accordance with their cognitive status. As expected, verbal communication abilities deteriorate faster than the relationship aspects of communication as the disease progresses. In summary, CODEM amb is a reliable and valid instrument that can be used to collect important information with the ultimate aim of supporting communication with people with dementia.

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

PubMed

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

2017-10-10

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

Brief report: Multiprogram evaluation of reading habits of primary care internal medicine residents on ambulatory rotations.

PubMed

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

2006-05-01

To assess the reading habits and educational resources of primary care internal medicine residents for their ambulatory medicine education. Cross-sectional, multiprogram survey of primary care internal medicine residents. Second- and third-year residents on ambulatory care rotations at 9 primary care medicine programs (124 eligible residents; 71% response rate). 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. To stimulate residents' reading, residency programs should encourage patient- and case-based learning; require teaching assignments; and provide easy access to online curricula.

Usability Testing of Two Ambulatory EHR Navigators.

PubMed

Hultman, Gretchen; Marquard, Jenna; Arsoniadis, Elliot; Mink, Pamela; Rizvi, Rubina; Ramer, Tim; Khairat, Saif; Fickau, Keri; Melton, Genevieve B

2016-01-01

Despite widespread electronic health record (EHR) adoption, poor EHR system usability continues to be a significant barrier to effective system use for end users. One key to addressing usability problems is to employ user testing and user-centered design. To understand if redesigning an EHR-based navigation tool with clinician input improved user performance and satisfaction. A usability evaluation was conducted to compare two versions of a redesigned ambulatory navigator. Participants completed tasks for five patient cases using the navigators, while employing a think-aloud protocol. The tasks were based on Meaningful Use (MU) requirements. The version of navigator did not affect perceived workload, and time to complete tasks was longer in the redesigned navigator. A relatively small portion of navigator content was used to complete the MU-related tasks, though navigation patterns were highly variable across participants for both navigators. Preferences for EHR navigation structures appeared to be individualized. This study demonstrates the importance of EHR usability assessments to evaluate group and individual performance of different interfaces and preferences for each design.

Ambulatory estimation of mean step length during unconstrained walking by means of COG accelerometry.

PubMed

González, R C; Alvarez, D; López, A M; Alvarez, J C

2009-12-01

It has been reported that spatio-temporal gait parameters can be estimated using an accelerometer to calculate the vertical displacement of the body's centre of gravity. This method has the potential to produce realistic ambulatory estimations of those parameters during unconstrained walking. In this work, we want to evaluate the crude estimations of mean step length so obtained, for their possible application in the construction of an ambulatory walking distance measurement device. Two methods have been tested with a set of volunteers in 20 m excursions. Experimental results show that estimations of walking distance can be obtained with sufficient accuracy and precision for most practical applications (errors of 3.66 +/- 6.24 and 0.96 +/- 5.55%), the main difficulty being inter-individual variability (biggest deviations of 19.70 and 15.09% for each estimator). Also, the results indicate that an inverted pendulum model for the displacement during the single stance phase, and a constant displacement per step during double stance, constitute a valid model for the travelled distance with no need of further adjustments. It allows us to explain the main part of the erroneous distance estimations in different subjects as caused by fundamental limitations of the simple inverted pendulum approach.

Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Project.

PubMed

Schiff, Gordon D; Reyes Nieva, Harry; Griswold, Paula; Leydon, Nicholas; Ling, Judy; Federico, Frank; Keohane, Carol; Ellis, Bonnie R; Foskett, Cathy; Orav, E John; Yoon, Catherine; Goldmann, Don; Weissman, Joel S; Bates, David W; Biondolillo, Madeleine; Singer, Sara J

2017-08-01

Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas. In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts. Controlled trial of a 15-month intervention including exposure to a learning network, webinars, face-to-face meetings, and coaching by improvement advisors targeting "3+1" high-risk domains: test result, referral, and medication management plus culture/communication issues evaluated by survey and chart review tools. Chart reviews conducted at baseline and postintervention for intervention sites. Staff and patient survey data collected at baseline and postintervention for intervention and control sites. Chart reviews demonstrated significant improvements in documentation of abnormal results, patient notification, documentation of an action or treatment plan, and evidence of a completed plan (all P<0.001). Mean days between laboratory test date and evidence of completed action/treatment plan decreased by 19.4 days (P<0.001). Staff surveys showed modest but nonsignificant improvement for intervention practices relative to controls overall and for the 3 high-risk domains that were the focus of PROMISES. A consortium of stakeholders, quality improvement tools, coaches, and learning network decreased selected ambulatory safety risks often seen in malpractice claims.

Nightmares affect the experience of sleep quality but not sleep architecture: an ambulatory polysomnographic study.

PubMed

Paul, Franc; Schredl, Michael; Alpers, Georg W

2015-01-01

Nightmares and bad dreams are common in people with emotional disturbances. For example, nightmares are a core symptom in posttraumatic stress disorder and about 50% of borderline personality disorder patients suffer from frequent nightmares. Independent of mental disorders, nightmares are often associated with sleep problems such as prolonged sleep latencies, poorer sleep quality, and daytime sleepiness. It has not been well documented whether this is reflected in objectively quantifiable physiological indices of sleep quality. Questionnaires regarding subjective sleep quality and ambulatory polysomnographic recordings of objective sleep parameters were collected during three consecutive nights in 17 individuals with frequent nightmares (NM) and 17 healthy control participants (HC). NM participants reported worse sleep quality, more waking problems and more severe insomnia compared to HC group. However, sleep measures obtained by ambulatory polysomnographic recordings revealed no group differences in (a) overall sleep architecture, (b) sleep cycle duration as well as REM density and REM duration in each cycle and (c) sleep architecture when only nights with nightmares were analyzed. Our findings support the observation that nightmares result in significant impairment which is independent from disturbed sleep architecture. Thus, these specific problems require specific attention and appropriate treatment.

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

Ambulatory Physical Activity Performance in Youth With Cerebral Palsy and Youth Who Are Developing Typically

PubMed Central

Bjornson, Kristie F; Belza, Basia; Kartin, Deborah; Logsdon, Rebecca; McLaughlin, John F

2007-01-01

Background and Purpose Assessment of walking activity in youth with cerebral palsy (CP) has traditionally been “capacity-based.” The purpose of this study was to describe the day-to-day ambulatory activity “performance” of youth with CP compared with youth who were developing typically. Subjects Eighty-one youth with CP, aged 10 to 13 years, who were categorized as being in Gross Motor Function Classification System (GMFCS) levels I to III and 30 age-matched youth who were developing typically were recruited. Methods Using a cross-sectional design, participants wore the StepWatch monitor for 7 days while documenting average daily total step counts, percentage of all time active, ratio of medium to low activity levels, and percentage of time at high activity levels. Results The youth with CP demonstrated significantly lower levels of all outcomes than the comparison group. Discussion and Conclusion Daily walking activity and variability decreased as functional walking level (GMFCS level) decreased. Ambulatory activity performance within the context of the daily life for youth with CP appears valid and feasible as an outcome for mobility interventions in CP. PMID:17244693

Incorporating assessment and prescribing for ambulatory ailments skills into practice: An environmental scan of continuing education for pharmacist prescribing in Canada

PubMed Central

Habicht, Dana; Ng, Sheila; Dunford, Drena; Shearer, Brenna; Kuo, I fan

2017-01-01

Objectives: Pharmacists in Canadian provinces are at different stages of applying prescribing legislation into practice. The purpose of this environmental scan was to examine differences in legislation, remuneration, professional uptake, continuing education requirements and continuing education resources relating to pharmacist prescribing for ambulatory ailments, with a focus on continuing education. Methods: Data were collected between May and December 2016 using websites and communication with provincial professional regulatory bodies, advocacy bodies, drug coverage programs and other organizations that offer continuing education for pharmacists. Results: Training requirements to prescribe for ambulatory ailments vary provincially, including no training requirements, online tutorials and a comprehensive application process. Government-funded remuneration for prescribing services is absent in most provinces. Pharmacist uptake of the training required to obtain prescribing authority ranges from 30% to 100% of pharmacists. Continuing education programs on the topic of prescribing across the country include online courses, in-person courses, webinars, panel discussions and preparation courses. Conclusion: Many aspects of pharmacist prescribing for ambulatory ailments, including the style and content of continuing education resources, vary from province to province. Further research on this topic would help to determine the effect of these differences on the success of incorporating pharmacist prescribing into practice. PMID:28894501

The influence of abdominal obesity and chronic work stress on ambulatory blood pressure in men and women.

PubMed

Steptoe, A; Cropley, M; Griffith, J; Joekes, K

1999-11-01

To assess the influence of abdominal obesity and work stress (operationalised as low control over work) on ambulatory blood pressure on a working day and evening. 156 school teachers (58 men and 98 women) carried out ambulatory blood pressure and heart rate monitoring on a work day and evening. Cardiovascular activity was also measured under baseline conditions on another occasion, when body weight, height, waist and hip circumference were assessed. Perceived control over work was assessed by questionnaire, along with mental health, anger expression and social support. 126 participants repeated the protocol after 12 months. Waist/hip ratio was used as the index of abdominal obesity. Baseline blood pressure was positively associated with waist/hip ratio in men, but ambulatory blood pressure and heart rate were not independently related to waist/hip ratio or job control. However, blood pressure and heart rate recorded during the working day and evening were elevated in men with high waist/hip ratio who experienced low job control, independently of age and body weight. Effects for diastolic blood pressure and heart rate were replicated after 12 months. Body mass index was not related to blood pressure or heart rate during the day or evening after adjustment for age and waist circumference. Low job control was associated with poor psychological well-being, negative mood and lack of social support. The results are consistent with the hypothesis that abdominal obesity in men is characterised by a tendency towards heightened stress-induced physiological activation, but that this tendency will only be manifest in the presence of appropriate environmental challenges such as chronic work stress.

Sleep Duration and Its Association With Ambulatory Blood Pressure in a School-Based, Diverse Sample of Adolescents

PubMed Central

Gallagher, Martina R.; Eissa, Mona A.; Nguyen, Thong Q.; Chan, Wenyaw

2014-01-01

BACKGROUND Evidence is accumulating that sleep duration is related to blood pressure (BP) and hypertensive status, but the strength of the association varies by age, and findings are inconsistent for adolescents. This cross-sectional study tested the hypothesis that sleep duration, both during the night and during naps, would be negatively associated with ambulatory systolic BP (SBP) and diastolic BP (DBP) measured over 24 hours in adolescents. METHODS In this ethnically diverse (37% non-Hispanic black, 31% Hispanic, 29% non-Hispanic white, 3% other), school-based sample of 366 adolescents aged 11–16 years, ambulatory BP was measured every 30 minutes for 24 hours on a school day; actigraphy was used to measure sleep duration. Covariables included demographic factors, anthropometric indices, physical activity, and position and location at the time of each BP measurement. Mixed models were used to test day and night sleep duration as predictors of 24-hour SBP and DBP, controlling for covariables. RESULTS The mean sleep duration was 6.83 (SD = 1.36) hours at night, and 7.23 (SD = 1.67) hours over 24 hours. Controlling for duration of sleep during the day and covariables, each additional hour of nighttime sleep was associated with lower SBP (−0.57; P < 0.0001); controlling for nighttime sleep duration and covariables, each additional hour of daytime sleep was associated with lower SBP (−0.73; P < 0.001) and lower DBP (−0.50; P < 0.001). CONCLUSIONS Longer sleep duration was significantly associated with lower ambulatory SBP and DBP in adolescents. The findings have potential implications for cardiovascular health in this age group. PMID:24487981

A portable automatic cough analyser in the ambulatory assessment of cough.

PubMed

Krajnik, Malgorzata; Damps-Konstanska, Iwona; Gorska, Lucyna; Jassem, Ewa

2010-03-14

Cough is one of the main symptoms of advanced lung disease. However, the efficacy of currently available treatment remains unsatisfactory. Research into the new antitussives requires an objective assessment of cough. The aim of the study was to test the feasibility of a new automatic portable cough analyser and assess the correlation between subjective and objective evaluations of cough in 13 patients with chronic cough. The patients' individual histories, a cough symptom score and a numeric cough scale (1-10) were used as a subjective evaluation of cough and a computerized audio-timed recorder was used to measure the frequency of coughing. The pre-clinical validation has shown that an automated cough analyser is an accurate and reliable tool for the ambulatory assessment of chronic cough. In the clinical part of the experiment for the daytime, subjective cough scoring correlated with the number of all cough incidents recorded by the cough analyser (r = 0.63; p = 0.022) and the number of cough incidents per hour (r = 0.60; p = 0.03). However, there was no relation between cough score and the time spent coughing per hour (r = 0.48; p = 0.1). As assessed for the night-time period, no correlation was found between subjective cough scoring and the number of incidents per hour (r = 0.29; p = 0.34) or time spent coughing (r = 0.26; p = 0.4). An automated cough analyser seems to be a feasible tool for the ambulatory monitoring of cough. There is a moderate correlation between subjective and objective assessments of cough during the daytime, whereas the discrepancy in the evaluation of night-time coughing might suggest that subjective analysis is unreliable.

Initial clinical experience with ambulatory use of an implantable atrial defibrillator for conversion of atrial fibrillation. Metrix Investigators.

PubMed

Daoud, E G; Timmermans, C; Fellows, C; Hoyt, R; Lemery, R; Dawson, K; Ayers, G M

2000-09-19

A recent study has shown that the implantable atrial defibrillator can restore sinus rhythm in patients with recurrent atrial fibrillation when therapy was delivered under physician observation. The objective of this study was to evaluate the safety and efficacy of ambulatory use of the implantable atrial defibrillator. An atrial defibrillator was implanted in 105 patients (75 men; mean age, 59+/-12 years) with recurrent, symptomatic, drug-refractory atrial fibrillation. After successful 3-month testing, patients could transition to ambulatory delivery of shock therapy. Patients completed questionnaires regarding shock therapy discomfort and therapy satisfaction using a 10-point visual-analog scale (1 represented "not at all," 10 represented "extremely") after each treated episode of atrial fibrillation. During a mean follow-up of 11.7 months, 48 of 105 patients satisfied criteria for transition and received therapy for 275 episodes of atrial fibrillation. Overall shock therapy efficacy was 90% with 1.6+/-1.2 shocks delivered per episode (median, 1). Patients rated shock discomfort as 5.2+/-2.4 for successful therapy and 4.2+/-2.2 for unsuccessful therapy (P:>0.05). The satisfaction score was higher for successful versus unsuccessful therapy (3.4+/-3. 3 versus 8.7+/-1.3, P:<0.05). There was no ventricular proarrhythmia observed throughout the course of this study. Ambulatory use of an implantable atrial defibrillator can safely and successfully convert most episodes of atrial fibrillation, often requiring only a single shock. Successful therapy is associated with high satisfaction and only moderate discomfort.

Transformation of anesthesia for ambulatory orthopedic surgery: A mixed-methods study of a diffusion of innovation in healthcare.

PubMed

Leggott, Kyle T; Martin, Matthew; Sklar, David; Helitzer, Deborah; Rosett, Randy; Crandall, Cameron; Vagh, Firoz; Mercer, Deana

2016-09-01

To provide insight into how an innovation in healthcare is implemented and diffused, we studied the transition from routine use of general anesthesia to peripheral nerve blocks (PNBs) for ambulatory orthopedic extremity surgery. Rogers' diffusion of innovations (DOI) theory was used as our theoretical framework. We identified themes that would be helpful for others attempting to diffuse innovations into healthcare settings. A mixed quantitative and qualitative methodology was used. We retrospectively reviewed operative and anesthesia records of patients who underwent ambulatory repair of distal radius fractures or arthroscopic knee meniscus procedures from 1998 to 2012 to identify whether general anesthetics or PNBs were used and the time course of the innovation. We interviewed orthopedic surgeons, anesthesiologists, and a nursing administrator working in the ambulatory surgery unit during the innovation to identify key themes associated with the adoption of PNBs. From 2003 to 2012, use of PNBs increased from less than 10% to 70% of cases studied. The adoption timeframe followed an S-shaped curve. Key themes included improved safety, quality, efficiency, physician leadership and trust, organizational structure, and technological change. The innovation involved an optional decision-making process and took root in a satellite facility and generally fit with Rogers DOI theory. The adoption and diffusion of PNBs provides a useful model for understanding innovations with optional decision-making in healthcare. Critical elements in our case were the characteristics of the innovation, which facilitated the decision-making process, and the positioning of the innovation in a peripheral structure away from core clinical facilities. Copyright © 2016 Elsevier Inc. All rights reserved.

Relationship between patient age and duration of physician visit in ambulatory setting: does one size fit all?

PubMed

Lo, Agnes; Ryder, Kathryn; Shorr, Ronald I

2005-07-01

To determine whether patient age, the presence of comorbid illness, and the number of prescribed medications influence the duration of a physician visit in an ambulatory care setting. A cross-sectional study of ambulatory care visits made by adults aged 45 and older to primary care physicians. A probability sample of outpatient follow-up visits in the United States using the National Ambulatory Medical Care Survey (NAMCS) 2002 database. Of 28,738 physician visits in the 2002 NAMCS data set, there were 3,819 visits by adults aged 45 and older included in this study for analysis. The primary endpoint was the time that a physician spent with a patient at each visit. Covariates included for analyses were patient characteristics, physician characteristics, visit characteristics, and source of payment. Visit characteristics, including the number of diagnoses and the number of prescribed medications, the major diagnoses, and the therapeutic class of prescribed medications, were compared for different age groups (45-64, 65-74, and > or =75) to determine the complexity of the patient's medical conditions. Endpoint estimates were computed by age group and were also estimated based on study covariates using univariate and multivariate linear regression. The mean time+/-standard deviation spent with a physician was 17.9+/-8.5 minutes. There were no differences in the duration of visits between the age groups before or after adjustment for patient covariates. Patients aged 75 and older had more comorbid illness and were prescribed more medications than patients aged 45 to 64 and 65 to 74 (P<.001). Patients aged 75 and older were also prescribed more medications that require specific monitoring and counseling (warfarin, digoxin, angiotensin-converting enzyme inhibitors, diuretics, and levothyroxine) than were patients in other age groups (P<.001). Hypertension, coronary artery disease, atrial fibrillation, congestive heart failure, cerebrovascular disease, and transient ischemic

Determinants of ambulatory treatment mode for mental illness.

PubMed

Freiman, M P; Zuvekas, S H

2000-07-01

We estimate a reduced-form bivariate probit model to analyse jointly the choice of ambulatory treatment from the specialty mental health sector and/or the use of psychotropic drugs for a nationally representative sample of US household residents. We find significant differences in treatment choice by education, gender, race and ethnicity, while controlling for several aspects of self-reported mental health and treatment attitudes. For example, while women are more likely than men to use the specialty mental health sector and more likely to take psychotropic medications, this difference between men and women is much greater for psychotropic medications. The estimated differences may reflect patient preferences in a manner traditionally assumed when interpreting these coefficients in such equations, but we discuss how they may also reflect biases and misperceptions on the parts of patients and providers. We also discuss how our results relate to some findings and policies in the general health care sector. Copyright 2000 John Wiley & Sons, Ltd.

Ambulatory EHR functionality: a comparison of functionality lists.

PubMed

Drury, Barbara M

2006-01-01

There is a proliferation of lists intended to define and clarify the functionality of an ambulatory electronic health record system. These lists come from both private and public entities and vary in terminology, granularity, usability, and comprehensiveness. For example, functionality regarding a problem list includes the following possible definitions: * "Create and maintain patient-specific problem lists," from the HL7 Electronic Health Record Draft Standard for Trial Use. * "Provide a flexible mechanism for retrieval of encounter information that can be organized by diagnosis, problem, problem type," from the Bureau of Primary Health Care. * "The system shall associate encounters, orders, medications and notes with one or more problems," from the Certification Commission on Health Information Technology. * "Displays dates of problems on problem list," from COPIC Insurance Co. * "Shall automatically close acute problems using an automated algorithm," from the Physicians Foundations HIT Subcommittee. This article will compare the attributes of these five electronic health record functionality lists and their usefulness to different audiences-clinicians, application developers and payers.

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

PubMed

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

2018-05-01

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

Replacing Ambulatory Surgical Follow-Up Visits With Mobile App Home Monitoring: Modeling Cost-Effective Scenarios

PubMed Central

Semple, John L; Coyte, Peter C

2014-01-01

Background Women’s College Hospital (WCH) offers specialized surgical procedures, including ambulatory breast reconstruction in post-mastectomy breast cancer patients. Most patients receiving ambulatory surgery have low rates of postoperative events necessitating clinic visits. Increasingly, mobile monitoring and follow-up care is used to overcome the distance patients must travel to receive specialized care at a reduced cost to society. WCH has completed a feasibility study using a mobile app (QoC Health Inc, Toronto) that suggests high patient satisfaction and adequate detection of postoperative complications. Objective The proposed cost-effectiveness study models the replacement of conventional, in-person postoperative follow-up care with mobile app follow-up care following ambulatory breast reconstruction in post-mastectomy breast cancer patients. Methods This is a societal perspective cost-effectiveness analysis, wherein all costs are assessed irrespective of the payer. The patient/caregiver, health care system, and externally borne costs are calculated within the first postoperative month based on cost information provided by WCH and QoC Health Inc. The effectiveness of telemedicine and conventional follow-up care is measured as successful surgical outcomes at 30-days postoperative, and is modeled based on previous clinical trials containing similar patient populations and surgical risks. Results This costing assumes that 1000 patients are enrolled in bring-your-own-device (BYOD) mobile app follow-up per year and that 1.64 in-person follow-ups are attended in the conventional arm within the first month postoperatively. The total cost difference between mobile app and in-person follow-up care is $245 CAD ($223 USD based on the current exchange rate), with in-person follow-up being more expensive ($381 CAD) than mobile app follow-up care ($136 CAD). This takes into account the total of health care system, patient, and external borne costs. If we examine

Tracking reflective practice-based learning by medical students during an ambulatory clerkship.

PubMed

Thomas, Patricia A; Goldberg, Harry

2007-11-01

To explore the use of web and palm digital assistant (PDA)-based patient logs to facilitate reflective learning in an ambulatory medicine clerkship. Thematic analysis of convenience sample of three successive rotations of medical students' patient log entries. Johns Hopkins University School of Medicine. MS3 and MS4 students rotating through a required block ambulatory medicine clerkship. Students are required to enter patient encounters into a web-based log system during the clerkship. Patient-linked entries included an open text field entitled, "Learning Need." Students were encouraged to use this field to enter goals for future study or teaching points related to the encounter. The logs of 59 students were examined. These students entered 3,051 patient encounters, and 51 students entered 1,347 learning need entries (44.1% of encounters). The use of the "Learning Need" field was not correlated with MS year, gender or end-of-clerkship knowledge test performance. There were strong correlations between the use of diagnostic thinking comments and observations of therapeutic relationships (Pearson's r=.42, p<0.001), and between diagnostic thinking and primary interpretation skills (Pearson's r=.60, p<0.001), but not between diagnostic thinking and factual knowledge (Pearson's r =.10, p=.46). We found that when clerkship students were cued to reflect on each patient encounter with the electronic log system, student entries grouped into categories that suggested different levels of reflective thinking. Future efforts should explore the use of such entries to encourage and track habits of reflective practice in the clinical curriculum.

Risk stratification of ambulatory patients with advanced heart failure undergoing evaluation for heart transplantation.

PubMed

Kato, Tomoko S; Stevens, Gerin R; Jiang, Jeffrey; Schulze, P Christian; Gukasyan, Natalie; Lippel, Matthew; Levin, Alison; Homma, Shunichi; Mancini, Donna; Farr, Maryjane

2013-03-01

Risk stratification of ambulatory heart failure (HF) patients has relied on peak VO(2)<14 ml/kg/min. We investigated whether additional clinical variables might further specify risk of death, ventricular assist device (VAD) implantation (INTERMACS <4) or heart transplantation (HTx, Status 1A or 1B) within 1 year after HTx evaluation. We hypothesized that right ventricular stroke work index (RVSWI), pulmonary capillary wedge pressure (PCWP) and the model for end-stage liver disease-albumin score (MELD-A) would be additive prognostic predictors. We retrospectively collected data on 151 ambulatory patients undergoing HTx evaluation. Primary outcomes were defined as HTx, LVAD or death within 1 year after evaluation. Average age in our cohort was 55 ± 11.1 years, 79.1% were male and 39% had an ischemic etiology (LVEF 21 ± 10.5% and peak VO(2) 12.6 ± 3.5 ml/kg/min). Fifty outcomes (33.1%) were observed (27 HTxs, 15 VADs and 8 deaths). Univariate logistic regression showed a significant association of RVSWI (OR 0.47, p = 0.036), PCWP (OR 2.65, p = 0.007) and MELD-A (OR 2.73, p = 0.006) with 1-year events. Stepwise regression showed an independent correlation of RVSWI<5gm-m(2)/beat (OR 6.70, p < 0.01), PCWP>20 mm Hg (OR 5.48, p < 0.01), MELD-A>14 (OR 3.72, p< 0.01) and peak VO(2)<14 ml/kg/min (OR 3.36, p = 0.024) with 1-year events. A scoring system was developed: MELD-A>14 and peak VO(2)<14-1 point each; and PCWP>20 and RVSWI<5-2 points each. A cut-off at≥4 demonstrated a 54% sensitivity and 88% specificity for 1-year events. Ambulatory HF patients have significant 1-year event rates. Risk stratification based on exercise performance, left-sided congestion, right ventricular dysfunction and liver congestion allows prediction of 1-year prognosis. Our findings support early and timely referral for VAD and/or transplant. Copyright © 2013 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

Frequency characteristics of the heart rate variability produced by Cheyne-Stokes respiration during 24-hr ambulatory electrocardiographic monitoring.

PubMed

Ichimaru, Y; Yanaga, T

1989-06-01

Spectral analysis of heart rates during 24-hr ambulatory electrocardiographic monitoring has been carried out to characterize the heart rate spectral components of Cheyne-Stokes respiration (CSR) by using fast Fourier transformation (FFT). Eight patients with congestive heart failure were selected for the study. FFT analyses have been performed for 614.4 sec. Out of the power spectrum, five parameters were extracted to characterize the CSR. The low peak frequencies in eight subjects were between 0.0179 Hz (56 sec) and 0.0081 Hz (123 sec). The algorithms used to detect CSR are the followings: (i) if the LFPA/ULFA ratios were above the absolute value of 1.0, and (ii) the LFPP/MLFP ratios were above the absolute values of 4.0, then the power spectrum is suggestive of CSR. We conclude that the automatic detection of CSR by heart rate spectral analysis during ambulatory ECG monitoring may afford a tool for the evaluation of the patients with congestive heart failure.

Modifying physician behavior to improve cost-efficiency in safety-net ambulatory settings.

PubMed

Borkowski, Nancy; Gumus, Gulcin; Deckard, Gloria J

2013-01-01

Change interventions in one form or another are viewed as important tools to reduce variation in medical services, reduce costs, and improve quality of care. With the current focus on efficient resource use, the successful design and implementation of change strategies are of utmost importance for health care managers. We present a case study in which macro and micro level change strategies were used to modify primary care physicians' practice patterns of prescribing diagnostic services in a safety-net's ambulatory clinics. The findings suggest that health care managers using evidence-based strategies can create a practice environment that reduces barriers and facilitates change.

A corporate partner in the endoscopic ambulatory surgery center. Is it worth the cost?

PubMed

Frakes, James T

2002-04-01

In the preceding article of this two-part polemic on the advisability of a corporate partner in the endoscopic ambulatory surgery center (EASC), the advantages of such a partner were discussed and criteria given for judging its performance. Alternatives to the corporate partner were discussed. In that article, the corporate partnership in the EASC is a positive development yielding many benefits and few disadvantages to the physicians and the center. In this article, the balance tilts the other way.

A pragmatic approach to infection prevention and control guidelines in an ambulatory care setting.

PubMed

Ng, Jessica; Le-Abuyen, Sheila; Mosley, Jane; Gardam, Michael

2014-06-01

The vast majority of infection prevention and control (IPAC) experience and practice guidance relates to the inpatient setting. We have taken a pragmatic approach to applying IPAC guidance in our ambulatory setting, and here we identify and describe the 4 key areas where we modified our IPAC program and adapted current guidelines to fit with our setting. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

Long-Term Continuous Ambulatory ECG Monitors and External Cardiac Loop Recorders for Cardiac Arrhythmia: A Health Technology Assessment

PubMed Central

Kabali, Conrad; Xie, Xuanqian; Higgins, Caroline

2017-01-01

Background Ambulatory electrocardiography (ECG) monitors are often used to detect cardiac arrhythmia. For patients with symptoms, an external cardiac loop recorder will often be recommended. The improved recording capacity of newer Holter monitors and similar devices, collectively known as longterm continuous ambulatory ECG monitors, suggests that they will perform just as well as, or better than, external loop recorders. This health technology assessment aimed to evaluate the effectiveness, cost-effectiveness, and budget impact of longterm continuous ECG monitors compared with external loop recorders in detecting symptoms of cardiac arrhythmia. Methods Based on our systematic search for studies published up to January 15, 2016, we did not identify any studies directly comparing the clinical effectiveness of longterm continuous ECG monitors and external loop recorders. Therefore, we conducted an indirect comparison, using a 24-hour Holter monitor as a common comparator. We used a meta-regression model to control for bias due to variation in device-wearing time and baseline syncope rate across studies. We conducted a similar systematic search for cost-utility and cost-effectiveness studies comparing the two types of devices; none were found. Finally, we used historical claims data (2006–2014) to estimate the future 5-year budget impact in Ontario, Canada, of continued public funding for both types of longterm ambulatory ECG monitors. Results Our clinical literature search yielded 7,815 non-duplicate citations, of which 12 cohort studies were eligible for indirect comparison. Seven studies assessed the effectiveness of longterm continuous monitors and five assessed external loop recorders. Both types of devices were more effective than a 24-hour Holter monitor, and we found no substantial difference between them in their ability to detect symptoms (risk difference 0.01; 95% confidence interval −0.18, 0.20). Using GRADE for network meta-analysis, we evaluated the

A Study to Develop a Model for the Allocation of Medical Supply Funds to the Various Clinical Services at Keller Army Community Hospital Based Upon Inpatient Weighted Units and Ambulatory Weighted Units

DTIC Science & Technology

1989-05-11

zDiagnosis Related Groups (DRGs), as developed by ther Mz researchers at Yale University in the late 1960s, were a m mmeans of classifying patients by...the group’s recalibration of the Rickard 19 ambulatory portion of the HCU was most important. This was because it resulted in, "an ambulatory

Intrathecal dexmedetomidine as adjuvant for spinal anaesthesia for perianal ambulatory surgeries: A randomised double-blind controlled study.

PubMed

Nethra, S S; Sathesha, M; Dixit, Aanchal; Dongare, Pradeep A; Harsoor, S S; Devikarani, D

2015-03-01

The newer trend in regional anaesthesia for ambulatory anorectal surgeries advocate use of lower dose of local anaesthetic, providing segmental block with adjuvants such as opioids and α2 agonists to prolong analgesia. The current study investigated effects of addition of 5 μg of dexmedetomidine to 6 mg of hyperbaric bupivacaine on duration of analgesia, sensory and motor block characteristics for perianal ambulatory surgeries. This study is a prospective randomised controlled double blind study. Forty adult patients between 18 and 55 years of age were divided into 2 groups. Group D received intrathecal 0.5% hyperbaric bupivacaine 6 mg (1.2 ml) with injection dexmedetomidine 5 μg in 0.5 ml of normal saline and Group N received intrathecal 0.5% hyperbaric bupivacaine 6 mg (1.2 ml) with 0.5 ml of normal saline. The parameters assessed were time to regression of sensory blockade, motor blockade, ambulation, time to void, first administration of analgesic. Statistical analysis was done using appropriate tests. Time for regression of sensory level and time for first administration of analgesic were prolonged in Group D (430.05 ± 89.13 min, 459.8 ± 100.9 min, respectively) in comparison to Group N (301.10 ± 94.86 min, 321.85 ± 95.08 min, respectively). However, the duration of motor blockade, time to ambulation, and time to void were also significantly prolonged in Group D (323.05 ± 54.58 min, 329.55 ± 54.06 min, 422.30 ± 87.59 min) than in Group N (220.10 ± 63.61 min, 221.60 ± 63.84 min, 328.45 ± 113.38 min). Intrathecal dexmedetomidine 5 μg added to intrathecal bupivacaine 6 mg as adjuvant may not be suitable for ambulatory perianal surgeries due to prolongation of motor blockade.

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