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Objective: Characterizing access to sudden sensorineural hearing loss (SSNHL) care at private practice otolaryngology clinics of varying ownership models., Study Design: Cross-sectional prospective review., Setting: Private practice otolaryngology clinics., Methods: We employed a Secret Shopper study design with private equity (PE) owned and non-PE-owned clinics within 15 miles of one another. Using a standardized script, researchers randomly called 50% of each clinic type between October 2021 and January 2022 requesting an appointment on behalf of a family member enrolled in either Medicaid or private insurance (PI) experiencing SSNHL. Access to timely care was assessed between clinic ownership and insurance type., Results: Seventy-eight total PE-owned otolaryngology clinics were identified across the United States. Only 40 non-PE clinics could be matched to the PE clinics; 39 PE and 28 non-PE clinics were called as Medicaid patients; 39 PE and 25 non-PE clinics were called as PI patients; 48.7% of PE and 28.6% of non-PE clinics accepted Medicaid. The mean wait time to new appointment ranged between 9.55 and 13.21 days for all insurance and ownership types but did not vary significantly (P > .480). Telehealth was significantly more likely to be offered for new Medicaid patients at non-PE clinics compared to PE clinics (31.8% vs 0.0%, P = .001). The mean cost for an appointment was significantly greater at PE clinics than at non-PE clinics ($291.18 vs $203.75, P = .004)., Conclusions: Patients seeking SSNHL care at PE-owned otolaryngology clinics are likely to face long wait times prior to obtaining an initial appointment and reduced telehealth options., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Background: There are known health disparities in adolescent substance treatment access and engagement. The purpose of this project is to compare outcomes from school- and clinic-based substance treatment and to evaluate if providing school-based substance treatment reduces disparities in treatment access and engagement., Method: This quality improvement retrospective chart review compares baseline and outcome data for adolescents accessing school-based (n = 531) and clinic-based (n = 523) substance treatment in a natural quasi-experimental study with nonequivalent control group design. Baseline demographic and clinical measures include age, sex, ethnicity, race, and clinical diagnoses. Outcome measures include the number of sessions completed, proportion reaching a week of self-reported abstinence, and proportion providing a negative urine drug screen., Results: Compared to the clinic-based sample, the school-based sample includes more female (47.65% vs 26.77%) and Hispanic/Latinx (59.89% vs 46.46%) adolescents. The school-based group has a similar proportion reaching a negative urine drug screen (31.84% vs 28.83%, p = .5259) or a week of abstinence (43.15% vs 41.03%, p = .6718) as the clinic-based sample. There are significant differences in total session completion over a period of 16 weeks between school-based and clinic-based adolescents. In multivariable analyses, there was a significant interaction effect of race/ethnicity by location on the number of sessions completed., Conclusion: Providing school-based substance treatment increases access to care and treatment engagement for female, African American, and Hispanic/Latinx adolescents without diminishing outcomes., (© 2023, American School Health Association.)

Background: Infusion therapy refers to the intravenous administration of medicines and fluids for the treatment of status migrainosus, severe persistent headaches, or chronic headache. Headache practices and centers offer this treatment for patients as an alternative to the emergency department (ED) setting. However, little information is available in the literature on understanding the operations of an infusion center., Objective: We sought to survey the Inpatient Headache & Emergency Medicine specialty section and the Academic Program Directors listserv of the American Headache Society (AHS) to better understand current practices., Methods: A survey was advertised and distributed to the listservs of both the Inpatient Headache & Emergency Medicine specialty section and the Academic Program Directors, which combined included both academic and private practices. In addition, the survey was available on laptops at related events at an annual AHS meeting in Scottsdale., Results: Of the 127 members of the combined group of both listservs, 50 responded with an overall survey response rate of 39%. Ten out of fifty were from programs with more than one responder completing the survey, leaving 40 unique headache programs. Academic programs made up the majority of programs (85%, 34/40). The total of 40 participating programs is comparable with the 47 academic headache programs listed on the American Migraine Foundation website at the time of the survey. Of the academic programs surveyed, most were hospital based (n = 23) compared with a satellite location (n = 11). Of all programs surveyed, 68% (27/40) offered infusion therapy. Of those that did not have an infusion practice (n = 13), the most common reason cited was insufficient staffing (n = 8). Key highlights of the survey included the following: The majority of programs offering infusions obtain prior authorization before scheduling (70%, 19/27) and offer patient availability 5 days/week (78%, 21/27) typically only during business hours (81%, 22/27). Programs reported that they typically give three to four medications during each infusion session (72%, 18/25). Treatment paradigms varied between programs. Programs surveyed were concentrated in the Northeast and Midwest regions of the United States., Conclusion: The limited number of headache infusion centers overall may contribute to the limited ability of headache infusion centers to prevent ED migraine visits. Headache patients can have unpredictable headache onset, and most of the infusion practices surveyed appeared to adapt to this by offering infusions most days during a work week. However, this need for multiple days per week may also explain the most common reason for not having an infusion practice, which is insufficient staffing. Various treatment paradigms are implemented by different practitioners, and future studies will have to focus on investigation of best practice., (© 2021 American Headache Society.)

Background: Medical abortion is usually offered in a clinic or hospital, but could potentially be offered in other settings such as pharmacies. In many countries, pharmacies are a common first point of access for women seeking reproductive health information and services. Offering medical abortion through pharmacies is a potential strategy to improve access to abortion., Objectives: To compare the effectiveness and safety of medical abortion offered in pharmacy settings with clinic-based medical abortion., Search Methods: We searched CENTRAL, MEDLINE, Embase, four other databases, two trials registries and grey literature websites in November 2020. We also handsearched key references and contacted authors to locate unpublished studies or studies not identified in the database searches., Selection Criteria: We identified studies that compared women receiving the same regimen of medical abortion or post-abortion care in either a clinic or pharmacy setting. Studies published in any language employing the following designs were included: randomized trials and non-randomized studies including a comparative group., Data Collection and Analysis: Two review authors independently reviewed both retrieved abstracts and full-text publications. A third author was consulted in case of disagreement. We intended to use the Cochrane risk of bias tool, RoB 2, for randomized studies and used the ROBINS-I tool (Risk Of Bias In Non-randomized Studies of Interventions) to assess risk of bias in non-randomized studies. GRADE methodology was used to assess the certainty of the evidence. The primary outcomes were completion of abortion without additional intervention, need for blood transfusion, and presence of uterine or systemic infection within 30 days of medical abortion., Main Results: Our search yielded 2030 records. We assessed a total of 89 full-text articles for eligibility. One prospective cohort study met our inclusion criteria. The included study collected data on outcomes from 605 women who obtained a medical abortion in Nepal from either a clinic or pharmacy setting. Both sites of care were staffed by the same auxiliary nurse midwives. Over all domains, the risk of bias was judged to be low for our primary outcome. During the pre-intervention period, the study's investigators identified a priori appropriate confounders, which were clearly measured and adjusted for in the final analysis. For women who received medical abortion in a pharmacy setting, compared to a clinic setting, there may be little or no difference in complete abortion rates (adjusted risk difference (RD)) 1.5, 95% confidence interval (CI) -0.8 to 3.8; 1 study, 600 participants; low certainty evidence). The study reported no cases of blood transfusion, and a composite outcome, comprised mainly of infection complications, showed there may be little or no difference between settings (adjusted RD 0.8, 95% CI -1.0 to 2.8; 1 study, 600 participants; very low certainty evidence). The study reported no events for hospital admission for an abortion-related event or need for surgical intervention, and there may be no difference in women reporting being highly satisfied with the facility where they were seen (38% pharmacy versus 34% clinic, P = 0.87; 1 study, 600 participants; low certainty evidence)., Authors' Conclusions: Conclusions about the effectiveness and safety of pharmacy provision of medical abortion are limited by the lack of comparative studies. One study, judged to provide low certainty evidence, suggests that the effectiveness of medical abortion may not be different between the pharmacy and clinic settings. However, evidence for safety is insufficient to draw any conclusions, and more research on factors contributing to potential differences in quality of care is needed. It is important to note that this study included a care model where a clinician provided services in a pharmacy, not direct provision of care by pharmacists or pharmacy staff. Three ongoing studies are potentially eligible for inclusion in review updates. More research is needed because pharmacy provision could expand timely access to medical abortion, especially in settings where clinic services may be more difficult to obtain. Evidence is particularly limited on the patient experience and how the care process and quality of services may differ across different types of settings., (Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Objectives: to Examine the practice characteristics of same-day clinic appointments and the use of same-day appointment scheduling to provide access to care in an otolaryngology-head and neck surgery clinic., Methods: Retrospective chart review of same-day clinic appointments from January 1, 2016, to December 31, 2018, in patients aged >19 years at a single academic center. Demographic data, diagnoses, procedures completed, and operations completed were analyzed., Results: There were 2696 visits by 2324 patients during the 3-year study period. More men than women (57% vs 43%) made same-day appointments. The mean age was 50.7 years (range, 19-99 years). Sinonasal and otologic diagnoses were the most frequently coded. A total of 1452 procedures were completed on the day of the visit, and 239 operations were completed as a result of the visit. Overall, a broad spectrum of otolaryngology care was delivered within the organizational new patient access goals., Discussion: Access to otolaryngology-head and neck surgery care can be challenging. Many patients will seek care when they feel they need it, and patient conditions can change unexpectedly. Offering same-day scheduling can allow patients timely health care and appropriate care., Implications for Practice: Same-day appointment scheduling can provide access to care and urgent care for patients. The department of otolaryngology-head and neck surgery has been able to maintain a high rate of providing new patient appointments within 10 days with this method. Further considerations for the impact of same-day scheduling on no-show rates and patient satisfaction can be evaluated.

Background: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services., Objectives: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects., Search Methods: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification., Selection Criteria: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings., Data Collection and Analysis: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes., Main Results: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies., Authors' Conclusions: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: Missed prevention opportunities are a financial burden to the US health care system and result in excess consumption of resources, reduced quality of life, increased morbidity, and premature death., Local Problem: High staff turnover and inefficient practices at a local health department caused long patient wait times and missed opportunities for preventive health care. The project aim was to improve timeliness through Right Care in a lower socioeconomic reproductive health clinic while decreasing patient cycle time by 10% in 90 days., Methods: We used four plan-do-study-act cycles incorporating tests of change that focused on team and patient engagement and two process changes. The interventions included a care coordination huddle, an infant feeding decision aid to better understand patient values, a sexual health screening tool to identify prevention opportunities, and a redesigned patient-centered discharge process to improve efficiency., Results: Over 90 days, the receipt of Right Care increased while patient cycle time decreased by 2.6%. The team improved function with a mean huddle effectiveness score increase from 2 to 4.4 (1-5 Likert scale). Intent to breastfeed increased by 49% (35%-52%), and identification of preventive care needs increased by 320% (15%-63%). Preventive care follow-up remained unchanged at 26% with the new discharge process, identifying weaknesses in the health department referral systems., Conclusions: Standardized tools and processes improved primary prevention opportunities at a local health department while reducing patient cycle time. The tools improved documentation of intent to exclusively breastfeed, increased preventive care identification, and streamlined the discharge process; while demonstrating a systems-level gap for long-term follow-up., (© 2020 Wiley Periodicals, Inc.)

Background: Emergency department (ED) patients with acute pulmonary embolism (PE) may undergo diagnostic pulmonary imaging as an outpatient before referral to the ED for definitive management. This population has not been well characterized., Methods: This retrospective cohort study included ambulatory adults with acute objectively confirmed PE across 21 EDs in an integrated health care system from January 1, 2013, through April 30, 2015. We excluded patients arriving by ambulance. We compared outpatients with diagnostic pulmonary imaging in the 12 hours prior to ED arrival (the clinic-based cohort) with those receiving imaging for PE only after ED arrival. We reported adjusted odds ratio (aOR) with 95% confidence intervals (CIs) for hospitalization, adjusted for race, presyncope or syncope, proximal clot location, and PE Severity Index class., Results: Among 2,352 eligible ED patients with acute PE, 344 (14.6%) had a clinic-based diagnosis. This cohort had lower PE Severity Index classification and were less likely to be hospitalized than their counterparts with an ED-based diagnosis: 80.8% vs. 92.0% (p < 0.0001). The inverse association with hospitalization persisted after adjusting for the above patient characteristics with aOR of 0.36 (95% CI = 0.26 to 0.50)., Conclusion: In the study setting, ambulatory outpatients with acute PE are commonly diagnosed before ED arrival. A clinic-based diagnosis of PE identifies ED patients less likely to be hospitalized. Research is needed to identify which patients with a clinic-based PE diagnosis may not require transfer to the ED before home discharge., (© 2020 by the Society for Academic Emergency Medicine.)

Background: We sought to develop a claims-based definition of unscheduled care to describe the use and role of the emergency department (ED) in providing unscheduled care to vulnerable older adult populations., Methods: This study was a cross-sectional analysis of national 20% sample of Medicare beneficiaries included in the 2012 Chronic Condition Warehouse data set. We measured three outcomes: the number of ED visits per 1,000 Medicare beneficiaries, the proportion of all unscheduled ED and office-based visits occurring in the ED and the number of ED and non-ED unscheduled visits adjusting for risk factors. Each outcome was estimated for vulnerable subpopulations of Medicare beneficiaries with multiple chronic conditions (MCCs), dual eligibility, hospice enrollment, and skilled nursing facility use., Results: A total of 10,717,786 Medicare beneficiaries were included with 33,696,461 potentially unscheduled care visits of which 5,192,235 (15%) occurred in the ED, 364,334 (1.1%) in facility-based urgent care, and 31,570,113 (84%) in ambulatory office settings. In regression analyses each subpopulation was more likely to visit the ED for unscheduled care services than the reference population of Medicare beneficiaries ages 65 to 80. Dual-eligible beneficiaries demonstrated higher ED visit rates and lower non-ED visit rates for unscheduled care. The subpopulation with MCCs uses both the ED and the non-ED setting for unscheduled care more so than any other group., Conclusions: Medicare beneficiaries, particularly vulnerable subpopulations, disproportionately visit the ED in comparison to physician offices for unscheduled care. Efforts to improve care coordination, measure quality, or reform payment to influence ED visitation should acknowledge these patterns and the unique availability of acute care services in the ED., (© 2020 by the Society for Academic Emergency Medicine.)

Background: Respiratory syncytial virus (RSV) is an important respiratory pathogen that affects people of all ages., Objectives: We examined the patterns of RSV circulation in 2014-2018, and investigated their age-specific differences in tropical Singapore., Methods: Nasopharyngeal and/or throat swabs were taken from outpatient attendees for the national influenza virological surveillance among those who presented with acute respiratory illness in the community. Specimens tested negative for influenza were then tested for RSV and other respiratory pathogens., Results: Among 8436 influenza-negative specimens tested during the five-year period, 5.8% (95% confidence interval 5.3%-6.3%) were positive for RSV. The peak of RSV activity occurred around middle of the year. The age-specific proportion of RSV detections showed a reverse J-shaped pattern; RSV positivity was the highest in young children ≤2 years of age (10.9%), followed by those aged 3-5 years (6.4%) and persons aged ≥65 years (5.3%), while the nadir was observed in the age group of 15-24 years (1.2%). RSV type A was predominantly circulating in children ≤5 years of age from 2014 to 2015 and 2017, whereas in 2016, they were more affected by type B., Conclusion: Respiratory syncytial virus was more frequently detected among the two age groups that have been recommended for influenza vaccination; persons ≥65 years of age and children 6 months to <5 years of age. Characterisation of RSV activity in the community helps to better inform public health policies for effective prevention and control interventions., (© 2020 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Objective: To describe components of the mobile surgical outreach (MSO) program as a model of care delivery for women with genital fistula; present program results; and discuss operational strengths and challenges., Methods: A retrospective observational study of routinely collected health data from women treated via the MSO program (2013-2018). The program was developed at Panzi Hospital in the Democratic Republic of Congo to meet the needs of women with fistula living in remote provinces, where travel is prohibited. It includes healthcare delivery, medico-surgical training, and community sensitization components., Results: The MSO team cared for 1517 women at 41 clinic sites across 18 provinces over the study period. Average age at presentation was 31 years (range, 1-81 years). Most women (n=1359, 89.6%) presented with vesicovaginal fistula. Most surgeries were successful, and few women reported residual incontinence postoperatively. Local teams were receptive and engaged in clinical skills training and public health education efforts., Conclusion: The MSO program addresses the backlog of patients awaiting fistula surgery and provides a template for a national strategic plan to treat and ultimately end fistula in DRC. It offers a patient-centered approach that brings medico-surgical care and psychosocial support to women with fistula in their own communities., (© 2020 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

An urgent care centre (UCC) is an upcoming trend in Swedish health care. Although UCCs have been established in other countries, their effectiveness and value have not yet been studied in Sweden. The aim of this study was to investigate the interaction between the UCC and emergency department (ED) by using validated evaluation models. One adult ED (AED) and one child ED (CED), together with a newly established UCC nearby, were included in this study. The interaction between the UCC team and the ED teams was studied by using two evaluation models: one for evaluation of integration and the other one for the evaluation of the effects, in terms of perceived relief of the ED after the establishment of the UCC. It was evident that integration was achieved early on in the course of the follow-up. However, the perception of integration varied between low (EDs) and high collaboration (UCC). All respondents of the EDs indicated relief, in terms of pace and pressure on the ED since the UCC was established. This study indicates that the grade of integration and collaboration between UCC and ED can be achieved automatically and very early during the establishment. It also shows that UCCs can be a competent complement to EDs and alleviate some of the heavy pressure placed on EDs due to ED overcrowding., (© 2019 John Wiley & Sons, Ltd.)

Background: Osteoporosis is one of the most under-diagnosed and under-treated health conditions in Canada. This study questioned whether an invitation to self-refer for osteoporosis risk evaluation would improve the number of patients who were tested for bone mineral density (BMD) at a rural Primary Health Care Center (PHCC)., Purpose: The purpose of this study is to improve osteoporosis care and decrease bone fracture risk in a population of patients 65 years of age and older., Methodology: A quasi-experimental research design was used to review screening rates of BMD testing and identified patients in this population who were at low, moderate, and high risk for developing osteoporosis. Screening rates at the PHCC were compared to screening rates at another rural PHCC in the province., Conclusion: The self-referral program for BMD testing and a nurse-led intervention resulted in an increased number of people who were BMD tested at the study PHCC compared with the control PHCC, and identified more male patients 65 years of age and older who were at risk for osteoporosis and bone fractures. Recommendations suggest future research in other provincial PHCCs that may encourage self-referral programs for BMD testing and improved osteoporosis care for patients 65 years of age and older., (© 2019 Wiley Periodicals, Inc.)

Reprocessing single-use surgical supplies and devices is an option for hospitals and ambulatory surgery centers (ASCs). The US Federal Government has recognized the practice since 2000, and regulatory oversight has increased dramatically since that time. Reprocessing single-use devices is safe when personnel use approved methods, and health care facilities can experience significant cost savings by participating in this type of initiative. This article explores reprocessing and its benefits in ASCs, including a review of the oversight that the US Food and Drug Administration currently has for reprocessing and a discussion of the results of studies pertaining to this practice. The article also describes some issues that ASC leaders need to be aware of when considering the implementation of a reprocessing program. Single-use device reprocessing can be an effective tool for ASC leaders to conserve and manage resources., (© AORN, Inc, 2019.)

Safe medication management is an important aspect of preventing patient harm. Medication management in the ambulatory setting can be complicated because of state and federal regulations and requirements imposed by accrediting organizations. Ambulatory surgery center leaders should review their medication management programs internally to assess their comprehensiveness in terms of efficiency, meeting regulatory requirements, and keeping patients safe. Partnering with a pharmacist or pharmacy consultant can be a useful way to address challenges with proper medication management. Perioperative medication use and administration, postoperative pain management, medication disposal, staff member and physician education, proper documentation in the medical record by all disciplines, pharmacoeconomics, pharmacy compounding needs, and controlled medication management and oversight are all important components of this segment of care. Ensuring that medication management programs at ambulatory surgery centers meet all regulatory and patient safety requirements is essential., (© AORN, Inc, 2019.)

Communication and other nontechnical skills can affect the number of adverse events occurring in perioperative areas. Our study assessed the properties of the Scrub Practitioners' List of Intraoperative Non-Technical Skills (SPLINTS) used to assess nontechnical skills of scrub nurses in a diverse Asian ophthalmic ambulatory setting. We evaluated the content validation index, cultural equivalence index, concurrent validity, interrater reliability, test-retest reliability, internal consistency, and concurrent validity. The content validity and cultural equivalence indices were 0.93 and 0.91, respectively. We found that the tool showed acceptable interrater reliability, acceptable test-retest reliability, and an appropriate Cronbach alpha ranging from 0.80 to 0.88. We found satisfactory concurrent validity between the SPLINTS and the communication and teamwork scale assessment (r s = 0.73, P < .001) and clinical teamwork scale (r s = 0.64, P < .001). We concluded that SPLINTS is a sound psychometric tool for assessing the nontechnical skills of culturally-diverse scrub persons in ambulatory surgery settings., (© AORN, Inc, 2019.)

Children with HIV are dependent on taking continuous medication and care, and family preparation is required when disclosing HIV. This study aimed to unveil families' experiences with HIV disclosure to children under 13 years old. Eight family members who have disclosed HIV to seropositive children were interviewed in-depth and individually. The fieldwork took place at a public paediatric outpatient hospital in Rio de Janeiro. The results showed that the family members' discourse highlighted two ways of knowing their own condition and disclosing the condition of the children with HIV. First, they needed to address the communication of bad news and discover their own HIV status through their children's disease. Second, the disclosure was a process constituted by four stages: preparing for disclosure, identifying the time, deciding how and where to tell, and instilling silence after disclosure. They also recognized that nurses had a role in the process as part of an interprofessional team. Nurses can develop advocacy care and empower family members in the preparation of safe HIV disclosure. By systematizing and institutionalizing the care advocacy process, nurses may enable caretakers and children to participate in their therapeutic management, improving adherence to the treatment and self-care with autonomy., (© 2018 John Wiley & Sons Ltd.)

Advances in surgical and anesthetic techniques have allowed for outpatient treatment of breast cancer. We evaluated the feasibility, safety, efficacy, and surgical outcomes of outpatient surgery in 370 patients with breast cancer who underwent breast-conserving surgery (BCS)/axillar lymph node (ALN) management. There were no deaths or severe intraoperative complications, but 41 complications were observed and disease recurrence occurred in 18 patients. The cumulative overall survival rate was 95.2%. Outpatient surgery was well tolerated, feasible, and safe in patients receiving BCS/ALN management., (© 2018 Wiley Periodicals, Inc.)

Objective: We compare case mix, hospitalization rates, length of stay (LOS), and resource use in independent freestanding emergency departments (FSEDs) and hospital-based emergency departments (H-EDs)., Methods: Data from 74 FSEDs (2013-2015) in Texas and Colorado were compared to H-ED data from the 2013-2014 National Hospital Ambulatory Medical Care Survey. In the unrestricted sample, large differences in visit characteristics (e.g., payer and case mix) were found between patients that use FSEDs compared to H-EDs. Therefore, we restricted our analysis to patients commonly treated in both settings (<65 years, privately insured, nonambulance) and used inverse propensity score weighting (IPW) to balance the two settings on observable patient characteristics. We then compared ED LOS and as well as hospital admission rates and resource utilization rates in the IPW-weighted samples., Results: Before balancing, FSEDs saw more young adults (age 25-44) and fewer older adults (age 45-64) than H-EDs. FSED patients had fewer comorbidities, more injuries and respiratory infections, and fewer diagnoses of chest or abdominal pain. In balanced samples, LOS for FSED visits was 46% shorter (60 minutes) than H-ED patients. Hospital admission rates were 37% lower overall (95% confidence interval = -51% to -23%) in FSEDs and varied considerably by primary discharge diagnosis. X-ray and electrocardiogram use was significantly lower at FSEDs while others measures of resource utilization were similar (ultrasound, computed tomography scans, and laboratory tests)., Conclusion: In this sample of FSEDs, a greater proportion of younger patients with fewer comorbidities and more injuries and respiratory system diseases were evaluated, and almost all patients had private health insurance. When restricted to < 65 years, privately insured, and nonambulance patients in both samples, LOS was considerably shorter and hospital admission rates lower at FSEDs, as well as the use of some diagnostic testing. This study is limited as diagnoses codes may not fully capture severity and patients who perceived greater need of hospital admission may have chosen a H-ED over FSEDs., (© 2018 by the Society for Academic Emergency Medicine.)

Background: Surveillance of influenza-like illness (ILI) in the United States is primarily conducted through medical settings despite a significant burden of non-medically attended ILI., Objectives: To assess consistency between surveillance for respiratory viruses in outpatient and community settings using ILI surveillance from the Centers for Disease Control and Prevention Influenza Incidence Surveillance Project (IISP) and the Mobile Surveillance for Acute Respiratory Infections (ARI) and Influenza-Like Illness in the Community (MoSAIC) Study., Methods: The Influenza Incidence Surveillance Project conducts ILI surveillance in 3 primary care clinics in New York City, and MoSAIC conducts community-based ILI/ARI surveillance through text messaging among a cohort of New York City residents. Both systems obtain respiratory specimens from participants with ILI/ARI and test for multiple pathogens. We conducted a retrospective review of ILI cases in IISP and MoSAIC from January 2013 to May 2015 with descriptive analyses of clinical and laboratory data., Results: Five-hundred twelve MoSAIC and 669 IISP participants met an ILI criteria (fever with cough or sore throat) and were included. Forty percent of MoSAIC participants sought care; the majority primary care. Pathogens were detected in 63% of MoSAIC and 70% of IISP cases. The relative distribution of influenza and other respiratory viruses detected was similar; however, there were statistically significant differences in the frequency that were not explained by care seeking., Conclusions: Outpatient and community-based surveillance in the one found similar timing and relative distribution of respiratory viruses, but community surveillance in a single neighborhood may not fully capture the variations in ILI etiology that occur more broadly., (Published 2018. This article is a U.S. Government work and is in the public domain in the USA. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Few studies have explored with standard measures patient satisfaction with care at the time of the diagnosis through rapid diagnostic pathways. This study aimed to assess satisfaction levels at the time of the diagnosis in a One-Stop Breast Unit and to examine associations with psychological states. An anonymous cross-sectional survey was conducted at a single center's One-Stop Breast Unit, to assess patient satisfaction regarding several aspects of the Unit. Two days after the diagnosis, 113 participants completed self-reported questionnaires evaluating satisfaction (Out-Patsat35), anxiety (State Anxiety Inventory), and psychological distress (Distress Thermometer). Overall, patients were very satisfied (80.7±20.7) with the One-Stop Breast Unit. The highest mean satisfaction scores concerned nurses' technical skills, interpersonal skills and availability. The lowest mean scores concerned physicians' availability, waiting time, and the provision of information. The results revealed a significant association between high state anxiety levels, lower levels of satisfaction with doctors' interpersonal skills (r=-.41, P<.001) and lower levels for information provided by nurses (r=-.38, P<.001). Moreover, greater psychological distress was associated with less satisfaction with the different aspects of care (doctors' interpersonal skills, doctors' availability and waiting-time). The results of regression models showed that doctor-related satisfaction scales explained 20% of the variance in anxiety (P<.01). Facing cancer diagnosis remains a stressful situation. However, our study suggested that a substantial part of this anxiety is sensitive to the quality of the patient-doctor relationship. Consequently, further efforts should be expended on adapting patient-doctor communication to improve patient reassurance., (© 2017 Wiley Periodicals, Inc.)

Decreasing wait time for pediatric dermatology appointments is important to patients. We retrospectively examined the effect of a referral-only policy on patient wait time for an initial appointment in an academic pediatric dermatology clinic and found a statistically significant decrease in wait time after the policy was instituted., (© 2017 Wiley Periodicals, Inc.)

Providing otolaryngology care to rural populations is a major challenge. In this study, we focus on rural outreach by the otolaryngology workforce in Iowa, a state with a high proportion of rural residents. Using data from 2013, we find that almost half (46%) of Iowa-based otolaryngologists participate in outreach. Along with colleagues from adjoining states, Iowa otolaryngologists staffed more than 2100 in-person clinic days in 76 mainly rural sites. This system of rural outreach has expanded access from 20 to 85 of the 99 counties in Iowa. These efforts improve access for more than 1 million residents out of a total population of 3 million. However, this improved level of access comes at a cost as visiting otolaryngologists drove an estimated 17,000 miles per month. This established approach to serving rural patients may be negatively impacted by changes under the Affordable Care Act., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.)

Background: Nineteen mass vaccination clinics were established in Montreal, Canada, as part of the 2009 influenza A/H1N1p vaccination campaign. Although approximately 50% of the population was vaccinated, there was a considerable variation in clinic performance and community vaccine coverage., Objective: To identify community- and clinic-level predictors of vaccine uptake, while accounting for the accessibility of clinics from the community of residence., Methods: All records of influenza A/H1N1p vaccinations administered in Montreal were obtained from a vaccine registry. Multivariable regression models, specifically Bayesian gravity models, were used to assess the relationship between vaccination rates and clinic accessibility, clinic-level factors, and community-level factors., Results: Relative risks compare the vaccination rates at the variable's upper quartile to the lower quartile. All else being equal, clinics in areas with high violent crime rates, high residential density, and high levels of material deprivation tended to perform poorly (adjusted relative risk [ARR]: 0·917, 95% CI [credible interval]: 0·915, 0·918; ARR: 0·663, 95% CI: 0·660, 0·666, ARR: 0·649, 95% CI: 0·645, 0·654, respectively). Even after controlling for accessibility and clinic-level predictors, communities with a greater proportion of new immigrants and families living below the poverty level tended to have lower rates (ARR: 0·936, 95% CI: 0·913, 0·959; ARR: 0·918, 95% CI: 0·893, 0·946, respectively), while communities with a higher proportion speaking English or French tended to have higher rates (ARR: 1·034, 95% CI: 1·012, 1·059)., Conclusion: In planning future mass vaccination campaigns, the gravity model could be used to compare expected vaccine uptake for different clinic location strategies., (© 2014 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Aims: Undertreatment with evidence-based pharmacotherapy for heart failure (HF) is an important problem, and it has been suggested that specialized HF clinics (HFCs) can improve treatment initiation and correct dosing. The objective of this study was to examine long-term adherence to and dosages of evidence-based pharmacotherapy during and after participation in specialized HFCs., Methods and Results: Initiation, dosages, and adherence were studied in patients with systolic HF attending HFCs in Denmark from 2002 to 2009. Information was obtained from an electronic patient file and research database used in the HFCs combined with prescription data from the Danish Registry of Medicinal Product Statistics. A total of 8792 patients were included in the study. The mean age was 68 years; with a mean LVEF of 30%, and 72% were males. Long-term adherence to treatment was high for the patients who initiated renin-angiotensin system (RAS) inhibitors and beta-blockers. Adherence after 1 year was 93% for RAS inhibitors, 92% for beta-blockers, and 86% for spironolactone. After 3 years, it was 90% for RAS inhibitors, 88% for beta-blockers, and 74% for spironolactone. For patients referred back to their general practitioner (GP), adherence 1 year after they left the HFC was 89% for RAS inhibitors, 89% for beta-blockers, and 72% for spironolactone., Conclusion: In specialized outpatient HFCs, long-term adherence to RAS inhibitors and beta-blockers is close to optimal. Importantly, adherence was maintained after patients were referred back to their GP for continued management. This is likely to provide long-term benefits for the patients.

Objective: To evaluate the capabilities and resources of free and charitable clinics in the United States to deliver musculoskeletal care to an indigent population., Design: A voluntary, anonymous, cross-sectional survey., Setting: Electronic mailing list for the National Association of Free and Charitable Clinics in September 2011, and in person at the Annual Summit for the National Association of Free and Charitable Clinics in October 2011. At the time of survey, 427 member-clinics were eligible for participation., Participants: One hundred forty-five (34%) respondents were included in data analysis., Interventions: None., Main Outcome Measures: Answers to a questionnaire regarding access to musculoskeletal care., Results: The average annual clinic volume was 5690 patient visits. Low back pain was the most common orthopedic complaint. Access to musculoskeletal specialty consultants was rated as poor or worse in 83% of clinics surveyed. The majority of respondents (63%) believed that their staff was able to treat only half or fewer of the patients who presented with musculoskeletal complaints in their clinic. The resource most needed to treat these conditions was musculoskeletal physician consultants., Conclusions: Indigent populations have a strong need for musculoskeletal care, but affordable access to physiatrists and other musculoskeletal specialists is extremely limited. Personnel at surveyed clinics believed that the greatest need to improve care is better access to these specialty physicians., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: Acute otitis externa (AOE) is a common but preventable ear condition. Clinical guidelines issued in 2006 recommended topical treatments for uncomplicated AOE, but systemic antimicrobials appear to be commonly prescribed. The objective of this analysis was to describe pre- and postguideline prescribing patterns by clinician specialty and antimicrobial type and assess trends over time., Study Design: Retrospective longitudinal analysis of a large insurance database., Setting: Outpatient departments in the United States., Methods: Initial outpatient visits in 2004 to 2010 for AOE (excluding visits with complicating conditions) were extracted from an insurance database. Prescription drug claims were linked and categorized by clinician specialty and antimicrobial type., Results: The analysis included 907,261 initial outpatient visits. Use of systemic antimicrobials declined by 4.9% (95% confidence interval [CI], 4.1%, 5.7%) from 36.5% of initial visits in 2004 to 32.1% in 2010. Use of systemic antimicrobials varied by specialty. Systemic antimicrobials were prescribed in 47.1% of 2010 emergency department (ED) visits (-6.9% from 2004, 95% CI -12.3, -1.5), 25.9% of otolaryngologist visits (-1.6%, 95% CI -5.6, 2.4), and 20.4% of pediatrician visits (-6.6%, 95% CI -8.8, -4.4). Penicillins were prescribed most frequently (42.3% of systemic prescriptions in 2010), followed by cephalosporins (19.8%), erythromycin/macrolides (17.4%), and quinolones (11.1%). Opioids were prescribed in 26.4% of ED visits and 9% of outpatient visits., Conclusions: Use of systemic antimicrobials declined over time, but one-third of 2010 visits resulted in systemic antimicrobials, despite exclusion of visits with complicating factors. Use of systemic antimicrobials varied by specialty. Further educational efforts and outreach to other specialties might be warranted.

Background: Early diagnosis of HIV infection reduces morbidity and mortality associated with late presentation. Despite UK guidelines, the HIV testing rate has not increased. We have introduced universal HIV screening in an open-access returning traveller clinic., Methods: Data were prospectively recorded for all patients attending the open-access returning traveller clinic between August 2008 and December 2010. HIV testing was offered to all patients from May 2009; initially testing with laboratory samples (phase 1) and subsequently a point-of-care test (POCT) (phase 2)., Results: A total of 4965 patients attended the clinic; 1342 in phase 0, 792 in phase 1 and 2831 in phase 2. Testing rates for HIV increased significantly from 2% (38 of 1342) in phase 0 to 23.1% (183 of 792) in phase 1 and further increased to 44.5% (1261 of 2831) during phase 2 (P < 0.0001). Two new diagnoses of HIV-1 were identified in phase 1 (1.1% of tested); seven patients had a reactive POCT test in phase 2, of whom five (0.4% of those tested) were confirmed in a 4th generation assay. The patients with false reactive tests had a concurrent Plasmodium falciparum infection. Patients travelling to the Middle East and Europe were less likely to accept an HIV test with POCT., Conclusions: A nurse-delivered universal point-of-care HIV testing service has been successfully introduced and sustained in an acute medical clinic in a low-prevalence country. Caution is required in communicating reactive results in low-prevalence settings where there may be alternative diagnoses or a low population prevalence of HIV infection., (© 2012 British HIV Association.)

Skin disorders are an important problem in children living in developing countries, but only a few epidemiologic investigations on pediatric dermatoses are available in the literature. Our study is an analysis of the range and frequency of skin diseases presenting to the Italian Dermatological Center in a pediatric Ethiopian population. A retrospective analysis was performed on 17,967 medical records of children aged 0 to 18 years attending the Italian Dermatological Centre in Mekele (Ethiopia) from January 2005 to December 2009. Infections and infestations accounted for 47% of the disorders seen; fungal infections were the most common (44.1%), followed by bacterial and parasitic diseases. Dermatitis constituted the second most common diagnostic category (24.7%) of the disorders seen, and contact dermatitis was the most common diagnosis (48.8%). Pigmentary disorders and disorders of skin appendages were more common in girls, whereas fungal and parasitic infections were more common in boys. Bacterial and parasitic infections were more common in children younger than 1 year old, fungal infections in those aged 1 to 5.9, and disorders of skin appendages and pigmentary disorders in those aged 15 to 18. These findings demonstrate that most of the disorders seen could be easily managed in clinical practice with appropriate skill development. It is crucial to ensure that training of medical students and pediatricians focuses on accurate recognition, diagnosis, and management of these common skin diseases and that families, teachers, health workers, and nurses be educated about the most common signs of prevalent skin diseases to help facilitate appropriate care., (© 2012 Wiley Periodicals, Inc.)

Objective: To describe the prevalence and nature of sex trade in a clinic-based sample of young women and to evaluate associations with sexual and reproductive health., Methods: A cross-sectional survey was conducted with women aged 16-29 years (n=1277) presenting to family-planning clinics in Northern California, USA., Results: Overall, 8.1% of respondents indicated a lifetime history of trading sex for money or other resources. Sex trade was associated with unintended pregnancy (adjusted risk ratio [ARR] 1.27; 95% confidence interval [CI], 1.09-1.48), multiple abortions (ARR 1.63; 95% CI, 1.19-2.23), STI diagnosis (ARR 1.46; 95% CI, 1.27-1.68), and unwanted sex (vaginal ARR 3.64; 95% CI, 2.39-5.56; anal ARR 4.99; 95% CI, 2.17-11.50). Of the women ever involved in sex trade, 12 (37.3%) reported that their first such experience was before they were 18 years of age., Conclusion: Approximately 1 in 12 participants had been involved in sex trade, illustrating the presence of patients with this history within the family-planning clinical setting. Sex trade was associated with multiple indicators of poor sexual and reproductive health. Family-planning clinics may represent an underused mechanism for engaging this high-risk population., (Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Background: Surveys of patients' experiences and views of health care usually focus on single services. During an unexpected episode of ill health, patients may make contact with different services and therefore experience care within an emergency and urgent care system. We developed the Urgent Care System Questionnaire and used it to describe patients' experiences and views of an emergency and urgent care system in England., Methods: A market research company used quota sampling and random digit dialling to undertake a telephone survey of 1000 members of the general population in July 2007., Results: 15% (151/1000) of the population reported using the emergency and urgent care system in the previous 3 months. Two thirds of users (68%, 98/145) contacted more than one service for their most recent event, with a mean of 2.0 services per event. Users entered the system through a range of services: the majority contacted a daytime GP in the first instance (59%, 85/145), and 12% (18/145) contacted either a 999 emergency ambulance or an emergency department. Satisfaction with all aspects of care diminished when four or more services had been contacted., Conclusions: This is the first study to describe patients' experiences and views of the emergency and urgent care system. The majority of patients experienced a system of care rather than single service care. There was an indication that longer pathways resulted in lower levels of patient satisfaction. Health care organisations can undertake similar surveys to identify problems with their system or to assess the impact of changes made to their system., (© 2011 Blackwell Publishing Ltd.)

Aims: Studies of heart failure (HF) incidence and prevalence frequently rely on hospitalization to identify patients. Our objective was to describe the incidence, prevalence, or outcomes for HF patients diagnosed in the outpatient or emergency department (ED) setting., Methods and Results: In a population-based study of 82,323 HF patients in a single-payer health-care system in Alberta, Canada from 1999 to 2007, we examined trends over time and clinical outcomes. Heart failure patients were first diagnosed in a general outpatient clinic (45.7%), a specialty outpatient clinic (4.0%), the ED (13.7%), or in hospital (36.6%). From years 2000 to 2006, the age-standardized incidence (per 100 000 population) decreased from 538 to 403, whereas the overall prevalence increased from 1585 to 2510. One-year mortality was significantly different among patients first diagnosed in a general outpatient clinic (6.6%), a specialty outpatient clinic (7.5%), ED (19.1%), and hospital (29.8%). Patients initially diagnosed at the time of hospitalization had the fewest median days alive and out of hospital [347, inter-quartile range (IQR): 136-363] over the next year compared with patients in the ED (354, IQR 313-365), specialty outpatient clinic (365, IQR 355-365), and general outpatient clinics (365, IQR: 359-365, P < 0.0001). Patients in the ED had the highest rate of subsequent ED visits, and all-cause, cardiovascular, or HF hospitalization., Conclusions: Over time, more patients were diagnosed as outpatients compared with a hospital setting. The trends observed in incidence, prevalence, and outcomes for patients with HF differ substantially depending on the location of initial diagnosis. Additionally, efforts to study patients with HF in the ED should be a priority.

Latent structure models have been proposed in many applications. For space-time health data it is often important to be able to find the underlying trends in time, which are supported by subsets of small areas. Latent structure modeling is one such approach to this analysis. This paper presents a mixture-based approach that can be applied to component selection. The analysis of a Georgia ambulatory asthma county-level data set is presented and a simulation-based evaluation is made., (Copyright (c) 2010 John Wiley & Sons, Ltd.)

Objectives: The purpose of this study was to generate data regarding the drug utilization pattern in pediatric population of our tertiary care hospital so that we could generate an essential medicine list (EML)., Background: Drug therapy accounts for a major portion of expenditure toward health care. Reduction in health care cost for an individual can be achieved by lowering the cost of drug treatment., Methods: This was an observational study conducted in the Advanced Pediatric Centre of our hospital, during which prescriptions and case records were reviewed., Results: During the study a total of 891 prescriptions were reviewed. Antibiotics and nutritional supplements were the major drugs prescribed. A large percentage of drugs were prescribed as trade names. Eighty three per cent of the drugs were prescribed from the National List Of Essential Medicine 2003 (India). Antibiotics accounted for the major bulk of cost of drugs, most of which were purchased by the patients., Conclusions: Restricted use of newer antibiotics, branded drugs and prescribing from the EML could be considered as targets for reduction of cost of therapy.

Objective: The aim of the study was to describe Veterans Healthcare Administration (VHA) system-wide uptake of three HIV protease inhibitors: atazanavir, darunavir and tipranavir., Methods: This retrospective cohort study evaluated VHA uptake of three target antiretrovirals and lopinavir/ritonavir in each complete 90-day quarter since approval to December 2007 using VHA HIV Clinical Case Registry data. We assessed uptake using number of new prescriptions, number of providers and facilities prescribing target agents, provider type, clinic type, facility size and location within four US regions., Results: Overall, 6551 HIV-infected veterans received target antiretrovirals. Uptake was generally greatest within the first year after Food and Drug Administration (FDA) approval, and then slightly declined and plateaued. Geographically, early adoption of new antiretroviral drugs tended to occur in the Western USA, as evidenced by comparison of uptake patterns of new antiretrovirals to use of all antiretroviral agents. A small percentage of prescribers of all antiretrovirals were responsible for new prescriptions for target medications, particularly for darunavir and tipranavir. Providers at almost 50% of VHA facilities were prescribing these agents within the first year., Conclusions: Uptake of new antiretrovirals in the VHA generally reflected overall prescribing of all antiretrovirals, suggesting a lack of VHA impediments to new antiretrovirals in the healthcare system. Some regional variation in uptake among the targeted antiretrovirals occurred over time but tended to resolve after the first several months. Providers responsible for early prescribing of the target medications were limited to a fraction of providers who tended to be physicians who practised in infectious disease (ID) clinics at medium-sized facilities.

Background and Purpose: Complementary and alternative therapy (CAT) use is frequent in patients with the common neurological disorders despite little scientific evidence of its efficacy. Little is known about the cost of regular CAT use. The purposes of this study were to determine the frequency and cost of CAT use in patients attending a neurology out-patient clinic and to determine whether neurological diagnosis affects CAT use., Methods: All patients attending the neurology out-patient clinic were asked to complete a structured questionnaire which included demographic information, details on the underlying neurological diagnosis, use and cost of CAT., Results: Six hundred and seventy-one patients completed the questionnaire. Over 60% of the patients had used CAT, and 25% used CAT on a regular basis. Only 25% of patients using CAT had informed their doctor. Rates of CAT use varied with neurological diagnosis. Of those using CAM on a regular basis, the mean annual cost was Euro 1351., Conclusion: Patients attending our neurology out-patient department use CAT frequently and often do not inform their doctor. Patients spend a significant amount of personal income on CAT. Given the implications, including potential interactions with prescribed medication, these findings should prompt doctors to ask every patient about CAT use.

Background: Information on prescribing practices in Palestine is lacking, however, still essential for strategic planning., Purpose: To characterise prescribing patterns and specific medicine use indicators in selected non-governmental organisations' (NGO) primary healthcare clinics/centres (PHC) in the West Bank (WB) in Palestine., Methodology: A prospective cross-sectional survey of prescribing practices based on medical records of 6032 patients with acute symptoms frequenting 41 NGO PHCs in the WB, between July and September 2004. A systematic random sample of every 10th patient appearing on the patient registration list was selected. Direct observation of consultation and dispensing practices and times in a sub-group of patients was completed utilising special forms., Results: Respiratory tract infections were the most commonly occurring conditions. On average, 1.9 drugs were prescribed per encounter and antibiotics were the most commonly prescribed medications, followed by Analgesics and NSAIDs accounting for 46 and 20% of the total medications expenditures, respectively. Injections and combined medications use per encounter was 16 and 8%, respectively. Most commonly prescribed medications were of local production. Consultation (6.4 +/- 4.6 minutes) and dispensing times (1.6 +/- 1.5 minutes) were short with inadequate labelling. Provision of reference sources and treatment guidelines implementation were also inadequate., Conclusion: The results suggest that prescribing practices could be improved through wider implementation of treatment guidelines, a review of antibiotic prescribing, and increased time spent with patients to promote concordance. Strategies aimed at improving prescribing and dispensing practices should be addressed through new innovative capacity building models based on problem solving and feedback mechanisms., (Copyright (c) 2008 John Wiley & Sons, Ltd.)

Objective: Sexual assault centers (SACs) aim at assisting victims and to provide forensic medical examination (FME). This study explores the gap between assaults actually occurring and those seen at SAC; and the characteristics of cases presented in time/too late for FME (early and late cohorts)., Design: Retrograde descriptive study., Setting and Sample: A two-year series from a self-referral SAC; characteristics of victims, assaults, use of services., Methods: Chi-quadrate, uni- and multivariate logistic regression analyses., Main Outcome Measures: Number of female victims seen/female at-risk population (attendance rates). Case and service profiles in the two cohorts. Adjusted odds for late presentation., Results: Attendance rates for females were 0.12% (14-55 years); an estimated 4-7% of sexually assaulted females in the catchment area. Two hundred and seventy eight victims arrived in time for FME, 76 later; 6% males. Assaults in the early cohort were more often performed by strangers. Two hundred and thirty-eight victims underwent FME, 55% complied with follow-up, 55% reported to the police. The late cohort contained more adolescent victims, more acquainted/partner perpetrators, more verbal coercion; 45% medically examined, 80% follow-up compliance; 34% reported to police. Further referrals occurred equally often in both cohorts; 12% to somatic and 39% to psychiatric services. Among victims seen, 5% died within 7 years of consultation., Conclusion: Cases seen at SAC are strongly selected. The late cohort seems more representative of the commonly occurring assaults; young victims, known assailants. Even late presenters are in need of a multidisciplinary approach.

Motor vehicle accidents (MVAs) are the leading cause of posttraumatic stress disorder (PTSD) in the general population, often with enduring symptomatology. This study details epidemiological and clinical features that characterize PTSD among MVA victims living in a nonhospitalized community setting long after the MVA event, and includes exploration of premorbid and peritraumatic factors. MVA victims (n=60; 23 males, 37 females) identified from the registry of a community general health outpatient clinic during a 7-year period were administered an extensive structured battery of epidemiological, diagnostic and clinical ratings. Results indicated that 30 subjects (50%; 12 males, 18 females) had MVA-related PTSD (MVAR-PTSD). Among those with PTSD, 16 individuals exhibited PTSD in partial remission, and six, in full remission. There were no significant demographic or occupational function differences between PTSD and non-PTSD groups. The most common comorbid conditions with MVAR-PTSD were social phobia (20%), generalized anxiety disorder (7.8%) and obsessive-compulsive disorder (0.5%). Previous MVA's were not predictive of PTSD. Subjects with MVAR-PTSD scored worse on the Clinician-Administered Posttraumatic Stress Disorder Scale, Part 2 (CAPS-2), Impact of Event Scale, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Impulsivity Scale, and Toronto Alexithymia Rating Scale. Study observations indicate a relatively high rate of PTSD following an MVA in a community-based sample. The relatively high rate of partially remitted MVAR-PTSD (N=16) underscores the importance of subsyndromal forms of illness. Alexithymia may be an adaptive method of coping with event stress. The development of PTSD appears not to be associated with the severity of MVA-related physical injury.

Objective: To document the results of a migraine patients survey, from a headache specialty clinic, in which patients were asked to rank, in order of importance, certain characteristics of migraine preventive treatment., Methods: A 10-question survey was completed by 150 patients (114 females and 36 males) with a history of migraine who presented to the Michigan Head Pain & Neurological Institute. The patients were asked to rank, in order of importance, characteristics of migraine preventive treatment. Each characteristic was rated individually on a 1 to 10 scale (1 being of little importance and 10 being extremely important). The mean rating of each characteristic was then calculated and the results analyzed., Results/discussion: From this migraine preventive treatment survey, the most important thing to migraineurs, from a headache specialty clinic population, is that the prescribing physician involves them in the decision making of choosing a preventive agent. The physician taking time to explain the possible medication side effects is the second most highly ranked characteristic. Migraine preventives with published efficacy in the medical literature are also deemed very important. Migraineurs do not mind using more than 1 preventive agent at one time if greater efficacy can be achieved. Agents that may affect weight and/or cause sedation may be important factors as to why patients (especially females) may not want to take a preventive medication. Natural therapies and once-daily dosing are ranked lower overall but still are important characteristics of preventive treatment. Some gender differences are noted in the ranking of migraine preventive characteristics.

Objective: To determine whether the addition of patient education to routine medical management improves the clinical status of migraine patients and reduces their utilization of healthcare resources., Background: Optimal migraine management typically requires effective patient education. Such education often is difficult to accomplish in the busy clinic setting., Methods: One hundred consecutive patients with migraine presenting to an university-based headache clinic were randomized to receive or not receive a standardized course of didactic instruction regarding migraine biogenesis and management. The course consisted of 3 classes taught by lay migraineurs who themselves previously had undergone intensive training. All patients were evaluated initially and at 1, 3, and 6 months by a neurologist blinded as to the results of randomization. Clinical variables examined included headache frequency/severity, migraine disability assessment (MIDAS) scores, patient compliance, presence versus absence of analgesic use/overuse, and headache-related unscheduled visits or phone calls. Comparisons were made between baseline findings and findings at the 6-month follow-up visit, with the change in mean MIDAS score serving as the primary outcome variable., Results: At 6 months the group randomized to receive intensive education exhibited a significantly greater reduction in mean MIDAS score than the group randomized to routine medical management only (24 vs. 14 points; P < .05). Those patients also experienced a reduction in mean headache days per month and a greater reduction in functionally incapacitating headache days per month, exhibited less analgesic overuse and need for abortive therapy, were more compliant with prophylactic therapy prescribed, and made fewer headache-related calls to the clinic or unscheduled visits., Conclusion: Intensive education of migraine patients by trained lay instructors may convey significant benefit to those patients and reduce their utilization of healthcare resources.

Issue Addressed: The incidence of skin cancer is rising in many populations around the world. In Australia, men have both the highest incidence of thick melanoma and an increased risk of dying from this disease. Skin screening may provide a method for detecting lesions at an earlier stage. This study sought to assess the impact of two methods of encouraging men to attend free open-access skin screening clinics., Methods: A randomised controlled trial of two recruitment methods. Subjects comprised all men aged 30 to 79 years (n=1,322) from a rural community. We randomly allocated 50% (661) to receive a personalised letter with the remaining 50% receiving the letter plus an additional brochure., Results: Both groups were similar in age distribution. A total of 250 men (18.9%) attended the skin screening clinic. Overall, there was no difference in rates of attendance between the two groups. Younger men (30 to 49 years) in the letter and brochure group were more likely to attend a clinic, while men > or =50 years in the letter only group were more likely to attend (p=0.01), Conclusions: These results indicate that a personalised letter or targeted approach of invitation is effective in encouraging men to attend a skin screening clinic. The addition of health information through the use of a glossy brochure did not increase screening participation among men over 50.

Recent data show that a high percentage of patients with systolic left ventricular dysfunction have sleep-disordered breathing (SDB), contributing to the incidence of morbidity and mortality in heart failure. This study examines the prevalence of sleep disorders in stable heart failure patients regardless of ejection fraction. On three consecutive days in a heart failure clinic, all patients were asked to participate in a screening for SDB. This screening involved the placement of an outpatient device (ClearPath, Nexan, Inc., Alpharetta, GA), which collects thoracic impedance, oxyhemoglobin saturation, and 2-lead electrocardiogram data. Sixteen patients (42%) had moderate or severe SDB, and 22 patients (55%) had mild or no significant SDB. Fourteen of the 16 patients with moderate or severe SDB subsequently received treatment by confirming SDB and the continuous positive airway pressure in a sleep lab. Forty-two percent of patients with stable heart failure presenting to a heart failure clinic screened positive for SDB, despite receiving optimal standard of care.

The majority of patients with primary headache do not seek medical help. In the present study we analyse the characteristics of those patients with primary headaches who consulted a single headache outpatient service in East Hungary. All consecutive patients with primary headaches referred to the headache center between February 2002 and April 2003 were asked to fill in a questionnaire on headache characteristics and the migraine disability score (MIDAS) form. A total of 327 patients had some form of primary headache: 42% migraine, 31% tension-type headache, 1% cluster headache and 26% had combination headache. Of the patients 95% were younger than 60 years of age. Only 16% of the patients were male. Chronic daily headache was found in 41% of patients. Although headache was the least severe in tension-type headache, reported disability occurred on much more days in this group than in migraine patients. The majority of patients with primary headache were in the active age group. Patients with tension-type headache need more attention, as disability is more severe in this patient group than generally assumed. More attention to the headaches of men and the elderly could improve the quality of life in these groups of the Hungarian population.

Background: Adequate periconceptional folic acid consumption lowers the risk for neural tube defects. We report the results of an evaluation of a folic acid intervention in Georgia family planning clinics that provided free folic acid supplements or fortified breakfast cereal., Methods: Six family planning clinics participated in the evaluation. Three clinics provided folic acid pills and educational materials to clients, two provided super-fortified cereal and educational materials, and one clinic provided educational materials only. Participants between the ages of 18 and 45 who visited the clinics in 2000 completed a brief survey and provided a blood sample. Of the 1093 women who participated, we evaluated the 165 women who had returned to the clinic at least once during the study period. We compared participants' survey and serum folate data from their first and subsequent visits., Results: Participation in the intervention was associated with increased knowledge about folic acid, (odds ratio, 1.94; 95% confidence interval, 1.37-2.76), but was not directly associated with increased self-reported folic acid consumption or increased serum folate levels. Reported use of folic acid supplements or cereal within two days of a visit was associated with higher serum folate levels. Knowledge about folic acid was one of the best predictors of self-reported folic acid consumption., Conclusions: Participation in the intervention increased clients' knowledge about folic acid but did not directly increase reported folic acid consumption. Because knowledge predicted folic acid consumption, the intervention may be indirectly associated with increased consumption of folic acid.

Objectives: To assess the suitability of cervical cancer screening in family planning (FP) clinics and the relevance for women's health., Methods: A survey was done on clients visiting the clinics of the Family Planning Association of Kenya (FPAK). Client characteristics, age, screening status and PAP smear results were registered. In-depth interviews were held with a limited number of staff and clients., Results: In 1999, 38052 clients visited FPAK clinics, 43.5% were younger than 30 years old. More than 10000 cervical smears were taken. A total of 4.5% of the smears were abnormal, including 1.5% high-grade squamous intraepithelial lesions (HSIL) and 0.2% invasive cancers. The clinics were well prepared to provide high quality screening services. Patients and staff had a positive view on screening., Conclusions: Providing cervical cancer screening in FP clinics is beneficial for the clients but is unlikely to have an impact on the epidemiology of cervical cancer morbidity as FP services reach only a small percentage of the women who are most at risk. Measures to reach more and older women could assure a larger impact.

Objectives: To find out which groups of people would use a National Health Service walk-in centre that would offer mainly health care advice, staffed by nurses. To understand the circumstances in which people would use a walk-in centre and to ascertain to what extent it would meet patients' expressed health-care needs., Design: A postal survey of 2400 people plus 27 semi-structured interviews and one focus group., Setting and Participants: The study was conducted in Wakefield, Yorkshire UK, and included both white and ethnic minority groups., Results: Most people reported that they would use a walk-in centre. It would be more attractive to young as compared with older people, ethnic minority as compared with white people, people who are dissatisfied with access to NHS services and people with urgent health-care problems. People want a wide range of services, including diagnosis, treatment, prevention, and general information. People also want access to both doctors and nurses, to male as well as female practitioners, to counsellors and interpreters. The type of service planned for this walk-in centre will meet some of the expressed needs. However, patients' expectations of the walk-in centre exceed planned provision in a number of key respects., Conclusion: Walk-in centres without GPs and with limited services will disappoint the public. It is important that walk-in centres are evaluated and attention paid to 'local voices' before additional money is allocated for such centres elsewhere.

Background: In Sweden heart failure is the most frequent discharge diagnosis within internal medicine. The prevalence of heart failure seems to be increasing, mainly due to an ageing population, but also because of improved survival in patients with cardiovascular diseases., Aim: To describe the epidemiology of heart failure in Sweden from a perspective based on demographic and health care data., Methods: The national registers in Sweden provide detailed information on health care consumption in relation to different diagnoses. Pharmaceutical sales are also registered. There are national epidemiological reports, reports on health care utilization and on health economics concerning heart failure patients., Results: There has been structural changes in the Swedish health care system due to financial restraints in the health care budget. Aiming at reducing hospital costs, the total amount of hospital beds has been cut down markedly during the last decade. The number of heart failure patients and the number of hospital stays have increased during the same period. Hospital stays have become shorter. The number of patients and hospital stays more than double when heart failure as both primary and secondary discharge diagnoses are included., Conclusion: The available national registers provide a good opportunity to study epidemiology of heart failure in Sweden. The number of hospital beds has decreased markedly within the last decade due to changes in the Swedish health care system. Nevertheless, there has been an increase in the number of patients discharged with heart failure from the hospitals, suggesting an increase in prevalence.