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Aim: To describe and to clarify the work of nurses in psychiatric outpatient care using a standardized nursing terminology and to describe the potential benefits and challenges in the use of the terminology., Design: A qualitative study of ethnographically grounded fieldwork in four adult outpatient units located in three major cities in Finland., Methods: A two-phase ethnographically oriented study, consisting of observations and focus group interviews in four psychiatric outpatient care units (in January-March 2018). During this process, the identified nursing interventions were mapped into the Nursing Interventions Classification., Results: We identified 93 different nursing interventions, covering all seven domains. Categories describing potential benefits and challenges were as follows: giving words to nurses' work and the challenge of overlapping interventions., Conclusion: Our findings indicate that the Nursing Interventions Classification is a suitable means to describe nursing in the psychiatric outpatient care setting. Our findings support the theory that describing nurses' work using a nursing terminology can make nursing visible and further empower nurses and help them to structure their work. The lack of other professionals, especially physicians, has led to nurses taking over new tasks officially and unofficially and we suggest that the issue needs to be studied further., Impact: Nurses' role in the psychiatric outpatient care has been described as invisible and difficult to describe. Our findings suggest that a nursing terminology can make nursing visible, not only from the perspective of patient health records but is also a way to conceptualize nurses' work., (© 2019 John Wiley & Sons Ltd.)

Background: Direct-to-consumer virtual visits are increasingly popular across both for-profit and nonprofit healthcare systems. Introduction: Virtual visits offer a convenient affordable way for patients to obtain medical care for simple conditions such as sinusitis and uncomplicated urinary tract infections. However, virtual visits have been associated with increased antibiotic utilization when compared with traditional in-person care. Methods: In this retrospective cohort study, antibiotic utilization for acute sinusitis was compared between patients treated through a direct-to-consumer virtual urgent care versus a matched cohort treated through traditional urgent care. Results: Fifty-seven patients were treated for acute sinusitis within the virtual care cohort, whereas 100 patients were treated in the traditional care arm. Antibiotic utilization for acute sinusitis was lower when care was delivered virtually using live-interactive video (67%) than when using traditional urgent care (92%) ( p < 0.001). When care was delivered virtually, age, gender, and care delivery modality (telephone vs. video) were not associated with antibiotic utilization for acute sinusitis. Discussion: Concerns have been raised that care delivered virtually does not meet expected quality standards when compared with traditional care. Antibiotic utilization has been used as an example of this quality gap. In this study, we demonstrate that antibiotic utilization was lower in a virtual care cohort than when care was delivered by emergency medicine physicians based in an academic setting. This suggests that awareness and sensitivity to prescribing guidelines may be more important than care delivery modality as it relates to antibiotic utilization. Conclusions: It is possible to deliver care virtually for acute sinusitis without increasing antibiotic utilization.

This study describes a simulation of diagnostic coding using an EHR. Twenty-three ambulatory clinicians were asked to enter appropriate codes for six standardized scenarios with two different EHRs. Their interactions with the query interface were analyzed for patterns and variations in search strategies and the resulting sets of entered codes for accuracy and completeness. Just over a half of entered codes were appropriate for a given scenario and about a quarter were omitted. Crohn's disease and diabetes scenarios had the highest rate of inappropriate coding and code variation. The omission rate was higher for secondary than for primary visit diagnoses. Codes for immunization, dialysis dependence and nicotine dependence were the most often omitted. We also found a high rate of variation in the search terms used to query the EHR for the same diagnoses. Changes to the training of clinicians and improved design of EHR query modules may lower the rate of inappropriate and omitted codes.

Objective: To determine the clinical validity and accuracy of an empirically derived triage model when compared with traditional priority assessment by receptionists., Background: The use of predictive models to support evidence-based delivery of health care is increasing. Predictive models assist in predicting priority of need or treatment planning for patients and facilitate transparent and consistent decision-making. A predictive model for determining priority of need for dental care was evaluated against a reference standard dentist assessment and traditional receptionist assessment., Methods: We sampled 310 patients seeking dental care. Participants were selected from people requesting care at two community dental clinics and who agreed to answer eight questions. Receptionists recorded their judgements of participant priority into three categories: care needed <48 h, 2-7 days or 8+ days. The 'reference standard' priority was determined by dental officers using the same categories. Model coefficients generated a predicted probability of requiring care. Sensitivity (Se), specificity (Sp), and predictive (PPV and NPV) and area under the curve (AUC) values were computed for two thresholds, <48 h versus 2+ days and <2-7 days versus 8+ days., Results: At <48-h threshold, the model PPV was higher and NPV lower than receptionists in predicting patients not needing care. At the 2- to 7-day threshold, the model also performed better than receptionists in predicting those needing care for 2-7 days. AUC statistics show the model performed better than the traditional receptionist method., Conclusions: The predictive model outperformed traditional receptionist screening in predicting priority of care., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: Ambulatory care-sensitive conditions (ACSC) foster to quality measurement in the ambulatory sector. The objective of this review is to provide an overview of existing catalogues of ACSC and to derive insights that support the plan-ned development of an ACSC catalogue for Germany., Methods: This article attempts to systemise the discussion on ACSC by delimiting the term from the related concepts of avoidable hospitalisations and avoidable diseases. Based on that, this article develops a definition of ACSC that is valid for the German context, makes a suggestion for the compilation of adequate diagnoses, and proposes how to apply an ACSC catalogue that is specific to Germany. An overview of nine central -articles describing the elaboration of ACSC catalogues in other countries and a first view of the diagnoses they comprise serve as a guidance., Results and Conclusion: The composition of an ACSC catalogue, that is adapted to the German context, is required to account for the local specifics of the German health-care system in order to ensure validity of the quality indicator. Such an outcome indicator for the ambulatory sector may mean a step towards a more outcome-oriented provision of care and may help ensure the quality of the German health-care system., (© Georg Thieme Verlag KG Stuttgart · New York.)

Musculoskeletal injuries (MSIs) are the most common cause of ambulatory visits in the deployed setting. Research done on deployed populations have focused mostly on men. The purpose of this retrospective cohort study was to describe physical demands and MSIs among male and female soldiers in a Brigade Combat Team during a 12-month deployment to Afghanistan. Data on occupational tasks and injuries were collected from the infantry and brigade support battalions. Out of 57 women, 22 had MSIs (39%) and for the 536 men, 120 (22%) had MSIs resulting in limited duty. The average limited duty was 7.5 and 13 days/injury for women and men, respectively. The most commonly injured body region for the men was the low back (32%) and the low back (22%) and foot and ankle (22%) for women. The activity associated with MSI for women was physical training (25%) and for men it was contact with the enemy (23%). Physically demanding duties, more distance walked, and heavier average load and objects lifted all increased the risk of injury in women. Only lifting heavier weights increased the risk in men. The women appear to have less tolerance to physically demanding work such than their male counterparts., (Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.)

As a part of the health care reform 2007 the German risk structure compensation scheme was extended so as to connect the financial cash flow towards the payers to morbidity information from ambulatory care. Within this context, morbidity information consists of prescriptions as well as coded ambulatory diagnoses. Accordingly, a high quality of coding is essential for a morbidity compatible allocation of funds. The aim of this study was to evaluate coding quality via qualifying characters as well as to identify future challenges. It focuses on diagnoses which are qualified as "assured" or "post-treatment" from about 350 million diagnoses of about 11 k practitioners' treatment of 2.7 million AOK PLUS insurants in Saxony and Thuringia during the years 2007-2010. The practitioners' documented diagnoses were aggregated within several groups according to the code of specialisation which is attached to the practitioner's 9-digit lifelong identification number (LANR). As a result, the number of "assured" diagnoses generally rose from year to year. Furthermore, diagnoses marked as "assumption" or "exclusion" remain constant over time. We identified a lack of diagnosis coding precision regarding the condition after certain medical events. In particular, general practitioners tend to use diagnosis codes qualified as "post-treatment" instead of using correct "assured" diagnoses qualified for conditions after certain events. Consequently, we expect adverse effects evaluating the cost of diseases as only "assured" diagnoses are considered within the risk transfer compensation scheme., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Effective communication between patients and health services providers is a key aspect for optimizing and maintaining these services. This work describes a system for the automatic evaluation of users' perception of the quality of SmsCup, a reminder system for outpatient visits based on short message service (SMS). The final purpose is the creation of a closed-loop control system for the outpatient service, where patients' complaints and comments represent a feedback that can be used for a better implementation of the service itself., Methods: SmsCup was adopted since about eight years by an Italian healthcare organization, with very good results in reducing the no-show (missing visits) phenomenon. During these years, a number of citizens, even if not required, sent a message back, with comments about the service. The automatic interpretation of the content of those SMS may be useful for monitoring and improving service performances.Yet, due to the complex nature of SMS language, their interpretation represents an ongoing challenge. The proposed system uses conditional random fields as the information extraction method for classifying messages into several semantic categories. The categories refer to appreciation of the service or complaints of various types. Then, the system analyzes the extracted content and provides feedback to the service providers, making them learning and acting on this basis., Results: At each step, the content of the messages reveals the actual state of the service as well as the efficacy of corrective actions previously undertaken. Our evaluations showed that: (i) the SMS classification system has achieved good overall performance with an average F1-measure and an overall accuracy of about 92%; (ii) the notification of the patients' feedbacks to service providers showed a positive impact on service functioning., Conclusions: Our study proposed an interactive patient-centered system for continuous monitoring of the service quality. It has demonstrated the feasibility of a tool for the analysis and notification of the patients' feedback on their service experiences, which would support a more regular access to the service., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Due to developments of the health market, economic aspects of the health system are more relevant. In this upcoming market the patient is regarded as customer and the doctor as provider of medical services. Studies on customer orientation in the ambulant medicine lag behind this dynamic. An aim of the study is to comprehend the attitudes of the doctors referring to the customer orientation. In a second step the findings are discussed according to statements of health-care paticipants. Developments in role comprehension of doctor and patient are focused to gain results in scientific and practical applications., Method: Guideline-supported, partly narrative interviews with n=9 gynaecologists and n=11 general practitioners in Freiburg/Germany are recorded, transcribed and reviewed in a qualitative analysis., Results: The statements of the doctors show patient satisfaction has an incremental meaning sspecially regarding the sequence of patient relationship and economic management of the doctor's workplace. The doctor's role comprehension meets with a refusal of the role of salesman and the patient as customer., Discussion: The method of interviews is suitable to gather empirical impressions of the doctors. The control sample is adequate, however a bias due to inhomogeneous thematic affinitiy and local social-demographics might be possible. The customer orientation has become an important factor in doctor-patient relationtships. The relevance of the doctor-patient conversation and the risk of misuse of the patient confidence are mentioned by the doctors. The doctor as paternalistic care provider gives way to the customer-focused service provider. The doctor's necessity of autonomyssss and dependency on patient satisfaction have potential for conflict., Conclusion: Intensive mention of customer orientation in medicine in the media emphasises its importance. Rational handling with the possibilities of individual health markets is a prospective challange. Further research could be established in all aspects of customer orientation, especially the changing relevance of ethical responsibility. An enlargement or comparison with other control samples (n>20, other medical subfields, structurally weak areas) could be illuminating. The results of this qualitative study can be used to develop quantitative inquiries., (© Georg Thieme Verlag KG Stuttgart · New York.)

Lawsuits in healthcare have increased exponentially in Brazil. However, the judicialization of healthcare procedures has not been sufficiently discussed, although such a discussion could broaden the scope of healthcare assessment. This study aimed to analyze the use of court action to ensure access to outpatient and hospital procedures from 1999 to 2009 in the State of Minas Gerais, Brazil. This was a retrospective descriptive study. Procedures were classified according to the Brazilian Unified National Health System (SUS) and the Table on Unified Terminology for Private Healthcare. Coverage by the SUS was 93.5%. The largest proportions of beneficiaries of such lawsuits lived in the Central and Western regions of the country (26.4% and 24%, respectively). The most common procedures involved in such cases were clinical admissions, admission to intensive care, and cardiovascular surgery. The study highlights the emerging need for access to medium and high-complexity procedures through extensive rules for coverage.

Objective: To analyze health care costs of patients with diabetes mellitus and hypertension, and to estimate the cost of medium complexity outpatient procedures, compared with the standard reimbursement values used in Brazil., Materials and Methods: We analyzed direct health costs in a public health reference unit in Recife/PE, in 2007. Costs were determined and allocated using the techniques of absorption costing and apportionment., Results: Direct costs and the amount reimbursed by the SUS totaled R$ 4,855,291.82 and R$ 2.118.893,56, respectively. The greatest groups of expenditure were medications, with R$ 1,762,424.42 (36.3%), outsourced services, with R$ 996,637.82 (20.5%); and personnel, with R$ 978,096.10 (20.1%). All procedures had higher estimated costs than what is reimbursed by the SUS., Conclusions: Drugs were associated with the highest health care costs, a considerable difference was observed between estimated costs and the amount reimbursed by the SUS.

Objective: Description of ambulatory care of AMI, in Quebec population., Design: A retrospective cohort study was designed to classify and propose a typology of ambulatory care., Methods: The studied population was included in all 25 years and older inpatients residing in Quebec, whose admission were from January to December 2000. The principal variables were: the number of medical visits, the type of consulted physicians and the place of consultation. The secondary variables were: age, sex and the presence of a revascularization., Results: A typology of ambulatory care was created from principal variables. Men, younger patients and receiving a revascularization in the index hospitalization were cared for by a specialist., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objectives: This report presents statistics on ambulatory care visits to physician offices, hospital outpatient departments (OPDs), and hospital emergency departments (EDs) in the United States in 2007. Ambulatory medical care utilization is described in terms of patient, provider, and visit characteristics., Methods: Data from the 2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were combined to produce annual estimates of ambulatory medical care utilization., Results: Patients in the United States made an estimated 1.2 billion visits to physician offices and hospital OPDs and EDs, a rate of 405.0 visits per 100 persons annually. This was not significantly different than the rate of 381.9 visits per 100 persons in 2006, neither were significant differences found in overall visit rates by age, sex, or geographic region. Visit distribution by ambulatory care setting differed by poverty level in the patient's ZIP Code of residence, with higher proportions of visits to hospital OPDs and EDs as poverty levels increased. Between 1997 and 2007, the age-adjusted visit rate increased by 11 percent, fueled mainly by a 29 percent increase in the visit rate to medical specialty offices. Nonillness and noninjury conditions, such as general and prenatal exams, accounted for the largest percentage of ambulatory care diagnoses in 2007, about 19 per 100 visits. Seven of 10 ambulatory care visits had at least one medication provided, prescribed, or continued in 2007, for a total of 2.7 billion drugs overall. These were not significantly different than 2006 figures. Analgesics were the most common therapeutic category, accounting for 13.1 drugs per 100 drugs reported, and were most often utilized at primary care and ED visits. The number of viral vaccines that were ordered or provided increased by 79 percent, from 33.2 million occurrences in 2006 to 59.3 million in 2007; significant increases were also noted for anticonvulsants and antiemetics.

Background: Care for people with dementia and their informal caregivers is a challenging aim in healthcare. There is an urgent need for cost-effective support programs that prevent informal caregivers of people with dementia from becoming overburdened, which might result in a delay or decrease of patient institutionalization. For this reason, we have developed the Systematic Care Program for Dementia (SCPD). The SCPD consists of an assessment of caregiver's sense of competence and suggestions on how to deal with competence deficiencies. The efficiency of the SCPD will be evaluated in our study., Methods and Design: In our ongoing, cluster, randomized, single-blind, controlled trial, the participants in six mental health services in four regions of the Netherlands have been randomized per service. Professionals of the ambulatory mental health services (psychologists and social psychiatric nurses) have been randomly allocated to either the intervention group or the control group. The study population consists of community-dwelling people with dementia and their informal caregivers (patient-caregiver dyads) coming into the health service. The dyads have been clustered to the professionals. The primary outcome measure is the patient's admission to a nursing home or home for the elderly at 12 months of follow-up. This measure is the most important variable for estimating cost differences between the intervention group and the control group. The secondary outcome measure is the quality of the patient's and caregiver's lives., Discussion: A novelty in the SCPD is the pro-active and systematic approach. The focus on the caregiver's sense of competence is relevant to economical healthcare, since this sense of competence is an important determinant of delay of institutionalization of people with dementia. The SCPD might be able to facilitate this with a relatively small cost investment for caregivers' support, which could result in a major decrease in costs in the management of dementia. Implementation on a national level will be started if the SCPD proves to be efficient., Trial Registration: NCT00147693.

The Ambulatory Patient Groups (APGs) are a patient classification system that was designed to be used as the basis of an Outpatient Prospective Payment System (OPPS). Although 6 major non-Medicare payers had implemented an APG-based OPPS between 1995 and 2000, the implementation of the Ambulatory Payment Classification (APC)-based Medicare OPPS shifted the focus of outpatient payment reform among payers to APC-based systems. Unfortunately, the APC OPPS is not really a prospective payment system and has become essentially a variant of a fee-for-service system. As a result, most major non-Medicare payers have rejected APCs as a model for outpatient payment reform and a renewed interest in the original APG OPPS design has occurred. This article reviews the basic components of an OPPS, compares and contrasts an APG- and APC-based OPPS, describes the differences between APG, Version 2.0, and APG, Version 3.0, and summarizes the key policy decisions payers will need to make in implementing an OPPS.

While the new ambulatory payment classification (APC) payment structure is seen by most ED observers as a positive move, it may not be a plus for your facility or your observation unit. Studying the new relative value units (RVUs) and your own case mix will tell your how your unit will fare. If the vast majority of your cases fall into Level 4 or Level 5, you may face a loss of revenue in 2008. The payment level for trauma care will be 33% lower in 2008. Compare your 2007 reimbursement for level 4 or 5 cases plus last year's observation payment with this year's new APC composite to project your likely revenue gain/loss.

This paper presents the results of a recent review of the Australian National Sub-acute and Non-acute Patient (AN-SNAP) classification system. The AN-SNAP system was developed by the Centre for Health Service Development, University of Wollongong in 1997. The review was conducted between August 2005 and September 2006. Four clinical sub-committees comprising more than 50 clinicians from sub-acute services across New South Wales as well as representatives from Queensland and the Australian Capital Territory were established to develop a set of proposals to be considered for incorporation into Version 2 of the classification. It is proposed that the final AN-SNAP Version 2 classification will be available for implementation from 1 July 2007.

Medicare's hospital outpatient prospective payment system (HOPPS) was initially developed in response to the rapid rise in Medicare's outpatient expenses between 1980 and 1991. The Balanced Budget Act of 1997 mandated HOPPS, with an implementation date of August 1, 2000. Unlike the Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) used hospital charge data to develop the ambulatory patient classification (APC) payment weights. During its evolution as a payment system, Congress mandated the creation of an advisory panel as well as the removal of diagnostic mammography from the APCs. The Deficit Reduction Act proposes applying HOPPS for paying technical fees in nonhospital settings.

Objective: To provide a summary of community and ambulatory pharmacy practice and billing patterns for medication therapy management services before implementation of Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA)., Design: Cross-sectional survey., Setting: Ambulatory care and community pharmacy practice settings in the United States in January 2004., Participants: Members of the American College of Clinical Pharmacy Ambulatory Practice and Research Network, preceptors of the American Pharmacists Association (APhA) Community Pharmacy Residency Programs, and participants in the APhA Immunizing Pharmacist listserv., Interventions: E-mail invitations to participate in a Web-based survey., Main Outcome Measures: Practice setting; pharmacy services performed; whether pharmacists were billing for pharmacy services; if billing, the billing technique used; if not billing, the reason for not billing., Results: Of 349 respondents, 127 (36.4%) were practicing within a physician office, while 121 (34.7%) were practicing in community pharmacies. Diabetes, anticoagulation, dyslipidemia, hypertension, and smoking cessation management services were performed significantly more often in physician offices. Immunization delivery and diabetes, dyslipidemia, and osteoporosis screenings were performed significantly more often in community settings. A total of 190 (54.5%) pharmacists stated that they were billing for pharmacy services. More community pharmacists were billing for services compared with other combined practice settings (69.2% versus 46.7%, P < .001). Top reasons identified for not billing for services were salaried position, indigent population, and discomfort with the billing process., Conclusion: Valuable baseline data are provided regarding pharmacy services that have been successfully implemented in ambulatory and community practice settings and which billing techniques were used to receive reimbursement before the implementation of MMA.

Background: The objective was to explore the usefulness of the morbidity risk adjustment system Adjusted Clinical Groups (ACG), in comparison with age and gender, in explaining and estimating patient costs on an individual level in Swedish primary health care. Data were retrieved from two primary health care centres in southeastern Sweden., Methods: A cross-sectional observational study. Data from electronic patient registers from the two centres were retrieved for 2001 and 2002, and patients were grouped into ACGs, expressing the individual combination of diagnoses and thus the comorbidity. Costs per patient were calculated for both years in both centres. Cost data from one centre were used to create ACG weights. These weights were then applied to patients at the other centre. Correlations between individual patient costs, age, gender and ACG weights were studied. Multiple linear regression analyses were performed in order to explain and estimate patient costs., Results: The variation in individual patient costs was substantial within age groups as well as within ACG weight groups. About 37.7% of the individual patient costs could be explained by ACG weights, and age and gender added about 0.8%. The individual patient costs in 2001 estimated 22.0% of patient costs in 2002, whereas ACG weights estimated 14.3%., Conclusion: ACGs was an important factor in explaining and estimating individual patient costs in primary health care. Costs were explained to only a minor extent by age and gender. However, the usefulness of the ACG system appears to be sensitive to the accuracy of classification and coding of diagnoses by physicians.

In Germany, the number and proportion of elderly people will continue to increase. Only few hospitals and rehabilitation units are currently providing inpatient geriatric services. Concepts for graded geriatric care see ambulatory geriatric rehabilitation (AGR) as an independent service und as a complement to pre-existing structures in geriatric care. In 2004, the national association of statutory health insurance funds established recommendations for AGR, which include criteria of structural and process quality of ambulant geriatric rehabilitation. This article describes various aspects of these framework recommendations (target groups, rehabilitation indicators, and equipment of services). In addition, the classification of AGR within the legislation of the statutory health insurance system is evaluated. The financing of AGR by the statutory health insurance system and the preconditions for accreditation of AGR-services within this system are discussed. The authors conclude that discrimination between existing partially-inpatient day clinics and AGR services is not appropriate. Furthermore, there is no legal basis for such a discrimination; on the contrary, the terms partially-inpatient and ambulatory rehabilitation services can be seen as a uniform benefit according to book 5 of the German social code, SGB V. Therefore there is no differentiation between AGR and partially-inpatient rehabilitation in the statutory health insurance system.

Objectives: To develop a palliative care casemix classification for use in all settings including hospital, hospice and home-based care., Sample: 3866 palliative care patients who, in a three-month period, had 4596 episodes of care provided by 58 palliative care services in Australia and New Zealand., Method: A detailed clinical and service utilization profile was collected on each patient with staff time and other resources measured on a daily basis. Each day of care was costed using actual cost data from each study site. Regression tree analysis was used to group episodes of care with similar costs and clinical characteristics., Results: In the resulting classification, the Australian National Sub-acute and Non-acute Patient (AN-SNAP) Classification Version 1, the branch for classifying inpatient palliative care episodes (including hospice care) has 11 classes and explains 20.98% of the variance in inpatient palliative care phase costs using trimmed data. There are 22 classes in the ambulatory palliative care branch that explains 17.14% variation in ambulatory phase cost using trimmed data., Discussion: The term 'subacute' is used in Australia to describe health care in which the goal--a change in functional status or improvement in quality of life--is a better predictor of the need for, and the cost of, care than the patient's underlying diagnosis. The results suggest that phase of care (stage of illness) is the best predictor of the cost of Australian palliative care. Other predictors of cost are functional status and age. In the ambulatory setting, symptom severity and the model of palliative care are also predictive of cost. These variables are used in the AN-SNAP Version 1 classification to create 33 palliative care classes. The classification has clinical meaning but the overall statistical performance is only moderate. The structure of the classification allows for it to be improved over time as models of palliative care service delivery develop.

Objectives: To provide a nontechnical discussion of the development of a palliative care casemix classification and some policy implications of its implementation., Sample: 3866 palliative care patients who, in a three month period, had 4596 episodes of care provided by 58 palliative care services in Australia and New Zealand., Method: A detailed clinical and service utilization profile was collected on each patient with staff time and other resources measured on a daily basis. A statistical summary of the clinical variables was compiled as the first stage of the analysis., Results: Palliative care phase was found to be a good predictor of resource use, with patients fairly evenly distributed across the five categories. Clients treated in an inpatient setting had poorer function and higher symptom severity scores than those treated in an ambulatory setting, a result that is not surprising in this Australian setting., Discussion: Implementation of the resultant AN-SNAP classification has been proceeding since 1998 in some Australian jurisdictions. The development and implementation of a classification such as AN-SNAP provides the possibility of having a consistent approach to collecting palliative care data in Australia as well as a growing body of experience on how to progressively improve the classification over time.

Objective: To describe patterns in ambulatory care sensitive (ACS) admissions at the zip code level based on zip code demographic and other characteristics. These patterns include trends over time, persistence within zip codes over time, and variation between and within socioeconomic strata., Data Sources: New York State hospital discharge data 1990-1998, U.S. census data 1990, and New York State birth records 1990., Study Design: Age- and sex-adjusted rates and volumes of ACS admissions are calculated at the zip code level. Descriptive statistics are analyzed cross-sectionally and over time. Kernel density functions are estimated across income strata. Ordinary and quantile regression techniques are used to determine the impact of socioeconomic variables on average and extreme values of the distribution of ACS admission rates., Principal Findings: Ambulatory care sensitive admissions rates declined during the study period but in conjunction with a greater decline in overall admission rates. Thus, as a percentage of total admissions, they actually rose by 4 percent. Ambulatory care sensitive admissions are geographically concentrated and rates are highly persistent within zip codes over time. Even on a log scale ACS admissions are typically greater and exhibit more variability among low-income zip codes. Other variables positively associated with ACS admissions are total population, births to unwed mothers (a proxy for family structure), black population, Hispanic population, and the number of non-ACS admissions. Births to immigrant mothers (a proxy for immigrant population) are negatively associated with ACS admissions., Conclusions: The concentration and persistence of ACS admissions point to a chronic, geographically limited deficiency of primary ambulatory care in the most underserved neighborhoods. Much of the difference in preventable hospitalization levels between high- and low-income areas is driven by very high volumes in the low-income areas unrelated to population density. New York data suggest that most costs from preventable hospitalizations could be saved by focusing on targeted neighborhoods. Socioeconomic and area utilization variables play a role in both average and extreme values of the rate of preventable hospitalizations at the zip code level. Since variables that affect the average volume of preventable hospitalizations can change the distribution of that volume, analysis based on averages alone may be inadequate. The findings on area demographics and non-ACS admissions point to the need to better understand social and cultural issues as well as local admitting practice patterns to encourage appropriate and efficient use of the health care delivery system.

Aim: To assess the feasibility and results of application of Ambulatory Patient Groups (APG) patient's classification system to the case-mix of patients seen at the Emergency Departments (ED) of 6 Barcelona metropolitan area hospitals., Methods: Development of a minimum discharge data set specific for the Emergency Departments (CMBDAU). Gathering of relevant variables from a random sample of patients seen at the ED using the ED discharge reports. Use of the APG classification system to those episodes., Results: A total of 11.188 episodes were codified and grouped with the APG system. Fifteen diagnostics identified 25% of all episodes. Nearly 50% of all procedures performed at the ED were common and simple procedures. Fifteen APG's grouped 50% of all cases seen at the ED., Conclusions: The ED Uniform Discharge Data Set (CMBDAU) developed is a valid instrument for describing the case-mix seen at the ED, and its grouping by means of the APG system provides consistent and meaningful results. The widespread use of systems like APG in the ED requires a former validation of relative weights assigned in the US system. The availability of human and technical resources must also be assessed, in order to guarantee the quality and sustainability of such a system.

Our study examines associations between race and ethnicity and hospitalization for ambulatory care sensitive (ACS) conditions for working age adults, and for individuals age 65 or older. We use ACS hospitalization as an outcome indicator to evaluate access to primary care. The prevalence of ACS conditions in the population, including those not hospitalized, and the occurrence of ACS and non-ACS hospitalization, are estimated using nationally representative data from the 1997 US Medical Expenditure Panel Survey. We calculate population-based relative rates of ACS hospitalization using the 1997 Nationwide Inpatient Sample, a large sample of United States' community hospitals, and the US Census. We investigate the sensitivity of these relative rates to the inclusion of conditions for which hospitalization varies notably across areas, and adjust the rates for both underlying hospitalization patterns for non-ACS conditions, and for disease prevalence in the population groups studied. The analyses consistently show that African Americans and Hispanics have significantly higher rates of ACS hospitalization than non-Hispanic whites. This result applies to women and men, and both age groups studied. These higher rates persist after adjusting for disease prevalence and non-ACS admission rates, and for the inclusion of high variation conditions.

Objectives: We evaluated primary care accessibility and quality for Ontario's aboriginal population., Methods: We compared a defined aboriginal cohort with nonaboriginal populations with analogous geographic isolation and low socioeconomic status. We determined rates of hospitalization for the following indicators of adequacy of primary care: ambulatory care-sensitive (ACS) conditions and utilization of referral care-sensitive (RCS) procedures from administrative databases., Results: ACS hospitalization rates, relative to the general population, were 2.54, 1.50, and 1.14 for the aboriginal population, the geographic control populations, and the socioeconomic control populations, respectively. The relative RCS procedure utilization rates were 0.64, 0.91, and 1.00, respectively., Conclusions: The increased ACS hospitalization rate and reduced RCS procedure utilization rate suggest that northern Ontario's aboriginal residents have insufficient or ineffective primary care.

Intensive outpatient mental health programs are proliferating rapidly. However, findings suggest that intensive treatment may be no more effective than standard treatment. This study compared standard to intensive outpatient programs, within both the psychiatric and substance abuse systems of care, on organization, staffing, and treatment orientation; clinical management practices; and services. A total of 723 (95% of those eligible) Department of Veterans Affairs programs were surveyed nationwide. Psychiatric intensive programs have responded appropriately to their more severely ill patients in terms of the amount and orientation of care, and having a rehabilitation focus. However, the relative lack of basic psychiatric services in psychiatric intensive programs, and the overall similarity of substance abuse standard and intensive programs, may explain why intensive programs have not yielded patient outcomes that are superior to those of standard programs. Mental health system planners should consider differentiating intensive programs using broader criteria and methods.

To encourage proper payment and avoid imposition of penalties by the Office of Inspector General, providers need to prioritize outpatient compliance efforts. Departments should be accountable for reconciling outpatient code editor edit failures. Evaluation and management code assignment should be examined for inter-rater reliability. Transitional pass-through items should be audited routinely; associated coding should be kept current. Consideration should be given to meeting medical necessity requirements, particularly for mental health services.

APCs are having a greater impact on hospital operations and processes than DRGs did. Coding must be correct, complete, and compliant. Billing processes should catch errors before claims are submitted. Information systems designed specifically for outpatient PPS are needed. Organizational changes may include naming an APC coordinator and a CDM manager and improving the working relationship between the HIM department and the billing office.

This article provides an overview of the outpatient prospective payment environment, a summary of early adopters, insights into its analytical and quality measurement capabilities, and financial impact data and coding statistics that will aid providers in the negotiation process.