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This work analysed the appointment system of outpatient clinics serving multiple patient classes with different flow sequences through the multi-phase-multi-server service system. Scarce resources are doctors, nurses and medical professionals with different start times and availability. Block appointment systems are typically used in public hospitals to help regulate patient flow while minimising patient waiting time, staff overtime and waiting room congestion. The patient scheduling problem in this complex environment is formulated by a mixed integer programme (MIP). Making use of waiting time information, an adaptive scheduling heuristic is designed to improve an initial schedule iteratively by identifying procedures with large average waiting times and reassigning their related patient classes to less congested time blocks probabilistically. An impact index based on the weighted multi-objective function is developed to allow servers select an available patient for the next treatment. A memory of distinct solutions is maintained to avoid recycling. Experiments are conducted based on a case study of an eye clinic in a public hospital. Performance is evaluated by comparing with the MIP and well-known dispatching rules for job shop scheduling problems. Sensitivity analysis is conducted for increase in appointment quota, two alternative staffing plans and changes in patient class distribution. [ABSTRACT FROM PUBLISHER]

The article aims to evaluate introduction of a new outpatient clinic safety checklist for ENT patients at the Whipps Cross Hospital based on the WHO Surgical Safety Checklist and reports on the efficiency of outpatient safety checklist in an effort to identify potential problems at the start of the clinic in order to improve patient safety and prevent delays and improve patient experience, and to preemptively identify any concerns.

Background Nationally, it is recommended that women should be offered post-dates induction of labour (IOL) at 40 weeks + 10–12 days. There is evidence that an outpatient IOL service may be associated with improved maternal satisfaction. Aims A home IOL service was developed to offer women choice about where labour onset can be awaited. Methods In an attempt to fully understand key factors and improve the local IOL service, a baseline audit of care and outcomes for low-risk post-dates women was undertaken (hospital group). A home IOL service was then set up (home group) for women to await labour onset in the comfort of their own home. Once this option was available, a second audit aimed to highlight any advantages or disadvantages with the new service so as to inform future improvement. Findings Audit findings highlighted that the majority of women remained at home for between 6–14 hours and all returned to the hospital safely. Conclusions Findings from the audits undertaken before, during and after the home IOL service was implemented, highlight useful benefits for women. It is recommended that other Trusts considering implementing the same improvement carefully monitor their findings. [ABSTRACT FROM AUTHOR]

Background The H. pylori eradication success is low in countries with high antibiotic resistance to H. pylori. Objective We retrospectively assessed the eradication rates achieved by five different regimens and aimed to compare the efficiency of bismuth enhanced sequential therapy and other treatments in a gastroenterology outpatient clinic a university-affiliated hospital. Design Our study was carried out with a retrospective cohort design. Setting This study assessed the gastroscopy examinations of patients. Patients A total of 621 patients were included in the study. There were 122 patients in the quadruple treatment group, 168 patients in the classical sequential treatment group, 130 patients in the bismuth enhanced sequential therapy, 113 patients in the sequential treatment with levofloxacin, and 88 patients in the hybrid treatment. Measurements Eradication rates of different regimens was analyzed by performing Chi-square and Tukey's honest significant difference test. Results Eradication rates by ITT and PP analysis achieved by treatment groups were 74.6 and 75.6% in the quadruple treatment; 70.2 and 70.4% in the sequential treatment with clarithromycin, 88.5 and 90.3% in the bismuth enhanced sequential therapy, 77.9 and 78.5% in the sequential treatment with levofloxacin, and 76.1 and 76.2% in the hybrid treatment. Limitations The main limitation of our study was its retrospective nature. Different proton pump inhibitors were used in the treatment arms. Conclusions Bismuth-enhanced sequential therapy can be recommended to overcome resistance. [ABSTRACT FROM AUTHOR]

Background: Little is known about the proportion and the characteristics of community-dwelling people with dementia (PWD) living alone in Germany.Objectives: To analyze the prevalence of PWD living alone (with and without the support of an informal caregiver) and socio-demographical and clinical characteristics as well as health and nursing care utilization associated with living alone.Methods: DelpHi-MV (Dementia: Life- and person-centered help in Mecklenburg-Western Pomerania) is a general practitioner-based, randomized controlled intervention trial. The present analyses are based on baseline data of 511 patients (≥70 years, community-dwelling) who had screened positive for dementia (DemTect <9).Results: N = 251 (51%) of the patients lived alone. PWD living alone were statistically significantly more often female, older, and more often widowed than those not living alone. About 9% of the patients (n = 24) were not supported by any informal caregiver. Regarding the clinical variables (cognitive and functional impairment, depression, falls, number of drug-related problems, malnutrition, quality of life), there were no statistically significant group differences. Patients living alone utilized professional services such as home care, help with medication, home-delivered meals, or housekeeping assistance significantly more often. Multivariate analyses confirmed these findings.Conclusion: Our results reveal the high proportion of PWD living alone in Germany. PWD living alone did not seem to be at an increased health risk. Our findings indicate that living alone with dementia is possible. In order to ensure the sufficient provision of health and nursing care services for PWD living alone, providers should consider the present results for future planning. [ABSTRACT FROM AUTHOR]

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

Background: Limb loss negatively impacts body image to the extent that functional activity and societal participation are affected. Scientific literature is lacking on the subject of cosmetic covering for prostheses and the rate of cosmetic cover utilization by cover type, gender, amputation level, and type of healthcare reimbursement.Objectives: To describe the delivery of cosmetic covers in lower limb prostheses in a sample of people with lower extremity amputation.Study Design: Cross-sectional designMethods: Patient records from an outpatient practice were reviewed for people who received a transtibial or transfemoral prosthesis within a selected 2-year period.Results: A total of 294 records were reviewed. Regardless of the amputation level, females were significantly (p ≤ 0.05) more likely to receive a cover. Type of insurance did not affect whether or not a cover was used, but Medicare reimbursed more pull-up skin covers.Conclusion: There were differences regarding cosmetic cover delivery based on gender, and Medicare reimbursed for more pull-up skin covers at the transtibial level than other reimbursors did. This analysis was conducted in a warm, tropical geographic region of the United States. Results may differ in other parts of the world based on many factors including climate and local views of body image and disability.Clinical Relevance: Cosmetic covering rates are clinically relevant because they provide insight into which gender is utilizing more cosmetic covers. Furthermore, it can be determined which type of covers are being utilized with greater frequency and which insurance type is providing more coverage for them. [ABSTRACT FROM AUTHOR]

Background: For optimal guidance of walking rehabilitation therapy of stroke patients in an in-home setting, a small and easy to use wearable system is needed. In this paper we present a new shoe-integrated system that quantifies walking balance during activities of daily living and is not restricted to a lab environment. Quantitative parameters were related to clinically assessed level of balance in order to assess the additional information they provide.Methods: Data of 13 participants who suffered a stroke were recorded while walking 10 meter trials and wearing special instrumented shoes. The data from 3D force and torque sensors, 3D inertial sensors and ultrasound transducers were fused to estimate 3D (relative) position, velocity, orientation and ground reaction force of each foot. From these estimates, center of mass and base of support were derived together with a dynamic stability margin, which is the (velocity) extrapolated center of mass with respect to the front-line of the base of support in walking direction. Additionally, for each participant step lengths and stance times for both sides as well as asymmetries of these parameters were derived.Results: Using the proposed shoe-integrated system, a complete reconstruction of the kinematics and kinetics of both feet during walking can be made. Dynamic stability margin and step length symmetry were not significantly correlated with Berg Balance Scale (BBS) score, but participants with a BBS score below 45 showed a small-positive dynamic stability margin and more asymmetrical step lengths. More affected participants, having a lower BBS score, have a lower walking speed, make smaller steps, longer stance times and have more asymmetrical stance times.Conclusions: The proposed shoe-integrated system and data analysis methods can be used to quantify daily-life walking performance and walking balance, in an ambulatory setting without the use of a lab restricted system. The presented system provides additional insight about the balance mechanism, via parameters describing walking patterns of an individual subject. This information can be used for patient specific and objective evaluation of walking balance and a better guidance of therapies during the rehabilitation.Trial Registration: The study protocol is a subset of a larger protocol and registered in the Netherlands Trial Registry, number NTR3636 . [ABSTRACT FROM AUTHOR]

Background: Gait is emerging as a powerful diagnostic and prognostic tool, and as a surrogate marker of disease progression for Parkinson's disease (PD). Accelerometer-based body worn monitors (BWMs) facilitate the measurement of gait in clinical environments. Moreover they have the potential to provide a more accurate reflection of gait in the home during habitual behaviours. Emerging research suggests that measurement of gait using BWMs is feasible but this has not been investigated in depth. The aims of this study were to explore (i) the impact of environment and (ii) ambulatory bout (AB) length on gait characteristics for discriminating between people with PD and age-matched controls.Methods: Fourteen clinically relevant gait characteristics organised in five domains (pace, variability, rhythm, asymmetry, postural control) were quantified using laboratory based and free-living data collected over 7 days using a BWM placed on the lower back in 47 PD participants and 50 controls.Results: Free-living data showed that both groups walked with decreased pace and increased variability, rhythm and asymmetry compared to walking in the laboratory setting. Four of the 14 gait characteristics measured in free-living conditions were significantly different between controls and people with PD compared to two measured in the laboratory. Between group differences depended on bout length and were more apparent during longer ABs. ABs ≤ 10s did not discriminate between groups. Medium to long ABs highlighted between-group significant differences for pace, rhythm and asymmetry. Longer ABs should therefore be taken into account when evaluating gait characteristics in free-living conditions.Conclusion: This study provides encouraging results to support the use of a single BWM for free-living gait evaluation in people with PD with potential for research and clinical application. [ABSTRACT FROM AUTHOR]

Objective: The primary goal of this analysis was to assess whether recent use of outpatient services for general medical concerns by Vietnam veterans varies according to level of posttraumatic stress disorder (PTSD) symptomatology over time. Another goal was to determine whether PTSD symptomatology was associated with veterans' reports of discussing behavioral health issues as part of a general medical visit.Methods: Self-reported service use data and measures of PTSD were from a nationally representative sample of 848 male and female Vietnam theater veterans (individuals who were deployed to the Vietnam theater of operations) who participated in the National Vietnam Veterans Longitudinal Study, a 25-year follow-up of a cohort of veterans originally interviewed from 1984-1988 as part of the National Vietnam Veterans Readjustment Study. Four categories of PTSD symptomatology course over 25 years were defined, and logistic regression models were used to assess their relationship with recent use of outpatient general medical services.Results: Male and female theater veterans with high or increasing PTSD symptomatology over the period were more likely than those with low symptomatology to report recent VA outpatient visits. Males in the increasing and high categories were also more likely to discuss behavioral health issues at general medical visits.Conclusions: Vietnam veterans with high and increasing PTSD symptomatology over time were likely to use VA outpatient general health services. Attention to stressors of the aging process and to persistence of PTSD symptoms is important for Vietnam veterans, as is addressing PTSD with other psychiatric and medical comorbidities within the context of outpatient general medical care. [ABSTRACT FROM AUTHOR]

Objective: In recent years, the co-existence in Germany of two parallel comprehensive insurance systems-statutory health insurance (SHI) and private health insurance (PHI)-has been posited as a possible cause of a persistent unequal regional distribution of physicians. The present study investigates the effect of the proportion of privately insured patients on the density of SHI-licensed physicians, while controlling for regional variations in the average income from SHI patients.Methods: The proportion of residents in a district with private health insurance is estimated using complete administrative data from the SHI system and the German population census. Missing values are estimated using multiple imputation techniques. All models control for the estimated average income ambulatory physicians generate from treating SHI insured patients and a well-defined set of covariates on the level of districts in Germany in 2010.Results: Our results show that every percentage change in the proportion of residents with private health insurance is associated with increases of 2.1 and 1.3 % in the density of specialists and GPs respectively. Higher SHI income in rural areas does not compensate for this effect.Conclusion: From a financial perspective, it is rational for a physician to locate a new practice in a district with a high proportion of privately insured patients. From the perspective of patients in the SHI system, the incentive effects of PHI presumably contribute to a concentration of health care services in wealthy and urban areas. To date, the needs-based planning mechanism has been unable to address this imbalance. [ABSTRACT FROM AUTHOR]

Background: Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume.Methods: We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries.Results: The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients' use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined.Conclusions: Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them. [ABSTRACT FROM AUTHOR]

Objective The aims of this review were to highlight fundamental distinctions between risk assessment in forensic versus therapeutic settings, review the best available evidence regarding key risk and protective factors for violence of particular relevance to clinicians in outpatient therapeutic settings, and describe an approach to evaluating and managing violence risk in outpatient treatment. Method An integrative literature review was undertaken to examine violence risk and protective factors most relevant to outpatient clinicians in therapeutic settings. Results Based on the available research, the Integrative Outpatient Violence Risk Assessment and Management (IVRAM) model, a 5-step strategy for evaluating and managing violence risk in therapeutic contexts, is introduced. The IVRAM emphasizes the integration of nomothetic and idiographic data through a focus on empirically derived dynamic risk and protective factors in the context of an individualized anamnestic analysis. Conclusion Clinicians working in forensic and therapeutic settings will increasingly benefit from the contributions of the other as the distinctions between risk assessment and risk management continue to decrease. [ABSTRACT FROM AUTHOR]

Background: Management of pain in the pre-hospital setting is often inadequate. In 2011, ambulance personnel were authorized to administer intravenous fentanyl in the Central Denmark Region. The aim of this study was to evaluate the efficacy and safety of intravenous fentanyl administered by ambulance personnel.Methods: Pre-hospital medical charts from 2348 adults treated with intravenous fentanyl by ambulance personnel during a 6-month period were reviewed. The primary outcome was the change in pain intensity on a numeric rating scale (NRS) from before fentanyl treatment to hospital arrival. Secondary outcomes included the number of patients with reduction in pain intensity during transport (NRS ≥ 2), the number of patients with NRS > 3 at hospital arrival, and potential fentanyl-related side effects.Results: Fentanyl reduced pain from before treatment (8, IQR 7-9) to hospital arrival (4, IQR 3-6) (NRS reduction: 3, IQR 2-5; P = 0.001), 79.3% of all patients had a reduction in > 2 on the NRS during transport, and 58.4% of patients experienced pain at hospital arrival (NRS > 3). Twenty-one patients (0.9%) had oxygen saturation < 90%. A decrease in Glasgow Coma Scale was seen in 31 patients (1.3%) and hypotension observed in 71 patients (3.0%).Conclusion: Intravenous fentanyl caused clinically meaningful pain reduction in most patients and was safe in the hands of ambulance personnel. Many patients had moderate to severe pain at hospital arrival. As the protocol allowed higher doses of fentanyl, feedback on effect and safety should be part of continuous education of ambulance personnel. [ABSTRACT FROM AUTHOR]

Objectives: To undertake a cost-effectiveness analysis of outpatient uterine polypectomy compared with standard inpatient treatment under general anaesthesia.Design: Economic evaluation carried out alongside the multi-centre, pragmatic, non-inferiority, randomised controlled Outpatient Polyp Treatment (OPT) trial. The UK National Health Service (NHS) perspective was used in the estimation of costs and the interpretation of results.Setting: Thirty-one secondary care UK NHS hospitals between April 2008 and July 2011.Participants: Five hundred and seven women with abnormal uterine bleeding and hysteroscopically diagnosed endometrial polyps.Interventions: Outpatient uterine polypectomy versus standard inpatient treatment. Clinicians were free to choose the technique for polypectomy within the allocated setting.Main Outcome Measures: Patient-reported effectiveness of the procedure determined by the women's self-assessment of bleeding at 6 months, and QALY gains at 6 and 12 months.Results: Inpatient treatment was slightly more effective but more expensive than outpatient treatment, resulting in relatively high incremental cost-effectiveness ratios. Intention-to-treat analysis of the base case at 6 months revealed that it cost an additional £9421 per successfully treated patient in the inpatient group and £ 1,099,167 per additional QALY gained, when compared with outpatient treatment. At 12 months, these costs were £22,293 per additional effectively treated patient and £445,867 per additional QALY gained, respectively.Conclusions: Outpatient treatment of uterine polyps associated with abnormal uterine bleeding appears to be more cost-effective than inpatient treatment at willingness-to-pay thresholds acceptable to the NHS.Tweetable Abstract: HTA-funded OPT trial concluded that outpatient uterine polypectomy is cost-effective compared with inpatient polypectomy. [ABSTRACT FROM AUTHOR]

Background: The presence of multiple chronic conditions (MCCs) complicates inpatient hospital care, leading to higher costs and utilization. Multimorbidity also complicates primary care, increasing the likelihood of hospitalization for ambulatory care sensitive conditions. The purpose of this study was to evaluate how MCCs relate to inpatient hospitalization costs and utilization for ambulatory care sensitive conditions.Methods: The 2012 Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) provided data to carry out a cross-sectional analysis of 1.43 million claims related to potentially preventable hospitalizations classified by the AHRQ Prevention Quality Indicator (PQI) composites. Categories of MCCs (0-1, 2-3, 4-5, and 6+) were examined in sets of acute, chronic, and overall PQIs. Multivariate models determined associations between categories of MCCs and 1) inpatient costs per stay, 2) inpatient costs per day, and 3) length of inpatient hospitalization. Negative binomial was used to model costs per stay and costs per day.Results: The most common category observed was 2 or 3 chronic conditions (37.8 % of patients), followed by 4 or 5 chronic conditions (30.1 % of patients) and by 6+ chronic conditions (10.1 %). Compared with costs for patients with 0 or 1 chronic condition, hospitalization costs per stay for overall ambulatory care sensitive conditions were 19 % higher for those with 2 or 3 (95 % confidence interval [CI] 1.19-1.20), 32 % higher for those with 4 or 5 (95 % CI 1.31-1.32), and 31 % higher (95 % CI 1.30-3.32) for those with 6+ conditions. Acute condition stays were 11 % longer when 2 or 3 chronic conditions were present (95 % CI 1.11-1.12), 21 % longer when 4 or 5 were present (95 % CI 1.20-1.22), and 27 % longer when 6+ were present (95 % CI 1.26-1.28) compared with those with 0 or 1 chronic condition. Similar results were seen within chronic conditions. Associations between MCCs and total costs were driven by longer stays among those with more chronic conditions rather than by higher costs per day.Conclusions: The presence of MCCs increased inpatient costs for ambulatory care sensitive conditions via longer hospital stays. [ABSTRACT FROM AUTHOR]

Background: Assertive Community Treatment (ACT) is more successful in reducing hospitalization when baseline use is high. However, with a growing recovery-focus, ACT may be useful for people with severe mental illness who are difficult to engage but not high users of inpatient services. This study investigated hospitalization 2 years before and 2 years after ACT enrollment amongst patients both with and without high inpatient services use before enrollment into ACT. Methods: This naturalistic observational study included 142 patients from 12 different ACT teams throughout Norway. Of these, 74 (52 %) were high users of inpatient services before ACT. The teams assessed the patients upon enrollment using clinician-rated and self-reported questionnaires. Hospitalization data from 2 years before and 2 years after enrollment into ACT were obtained from the Norwegian Patient Registry. Linear mixed models were used to assess changes in hospitalization and to explore associations between these changes and patient characteristics. Results: When the participants enrolled into the ACT teams, high users of inpatient care were younger, more often living alone and more often subject to involuntary outpatient treatment than low users. The participants spent significantly fewer days in hospital during the 2 years of ACT follow-up compared to the 2 years before enrollment. The reduction was more evident amongst high users, whereas low users had an initial increase in inpatient days in the first year of ACT and a subsequent decrease in the second year. More severe negative symptoms and previous high use of inpatient care were associated with a reduction in both total and involuntary inpatient days. Additionally, a reduction in involuntary inpatient days was associated with being subject to involuntary outpatient treatment upon enrollment into ACT. Conclusion: The findings in this study may suggest that ACT contributes to more appropriate use of inpatient care, possibly by reducing the presumably avoidable hospitalization of high users and increasing the presumably needed inpatient care of low users. [ABSTRACT FROM AUTHOR]

There is ever-increasing pressure on hospital resources in general and emergency departments (ED) in particular. At the same time, there is increasing recognition that traditional inpatient ward-based care is not necessary for the majority of children presenting to the ED with acute illness, and that there are patient, family and hospital benefits to pursuing other options. Here, we describe alternative pathways for children presenting to the ED, including short stay and observational medicine, hospital-in-the-home and non-admission enhanced care, in other words, additional management practices or pathways for children who are discharged from the ED. We discuss the principles, models and practical considerations involved in each of these. [ABSTRACT FROM AUTHOR]

Scoring systems to recognise the most ill patients, or those at risk of deterioration, are increasingly utilised in hospitals that look after paediatric inpatients. There have been efforts to implement these systems in emergency and urgent care settings, but they have yet unproven value. This is because the child or young person presenting acutely is a different cohort than the 'treated' ward-based group. The majority of children presenting to emergency and urgent care settings are discharged home, and so, scoring systems need to recognise the most unwell but also assist in safe and appropriate discharge as well as highlighting those patients in need of more senior review. This article explores this conundrum, suggesting how cognitive factors have a role to play, and how scoring systems can have wider effects than just individual patient care. [ABSTRACT FROM AUTHOR]

Purpose: To determine patient preferences for use of a chaperone during transvaginal sonography. Materials and methods: Informed consent was waived for this IRB-exempt, HIPAA-compliant, retrospective review of prospectively acquired quality improvement survey data. Willing unique consecutive adult patients (n = 155) scheduled to undergo a transvaginal pelvic ultrasound between March 1, 2015 and August 15, 2015 completed a survey before and after the ultrasound examination assessing their opinions regarding the need for a chaperone. Surveys were collected from three outpatient centers (n = 35/center) and an inpatient center (n = 50) in the same health system. Respondent opinions were compared with Chi-Square test or Fisher's Exact test. Results: Most respondents (78% [121/155]) had previously undergone a transvaginal pelvic ultrasound. Respondents were significantly more likely to prefer a chaperone if their sonographer was male than if their sonographer was female (pre-ultrasound: 46% [69/155] vs. 12% [19/155], p < 0.0001; post-ultrasound: 43% [66/155] vs. 6% [10/155], p < 0.0001). The fraction of respondents who said they would be somewhat or substantially reassured by a chaperone if their sonographer was female was similar to the fraction of respondents who said they would be somewhat or substantially embarrassed by presence of a female chaperone (pre-ultrasound: 12% [19/155] vs. 6% [9/155], p = 0.07; post-ultrasound: 6% [10/155] vs. 7% [11/155], p = 0.82; respectively). Conclusion: Approximately half of adult women scheduled to undergo transvaginal pelvic sonography prefer that a chaperone be present if their sonographer is male, but in general do not feel it is necessary if their sonographer is female. These opinions do not change after performance of a transvaginal pelvic ultrasound. [ABSTRACT FROM AUTHOR]

Background/Objectives For 8 years South Australian dermatologists have provided an outreach service to the Northern Territory ( NT), including rural and remote areas. In 2012 and 2013, a trainee accompanied a dermatologist on these outreach visits. This is the first prospective study that documents the spectrum of dermatological diseases requiring outpatient specialist input in various settings in the NT, and also the first study to compare the clinical experience of one Australian dermatology trainee in urban and rural settings. Materials and Methods Characteristics of patients managed primarily by the outreach dermatology registrar were recorded prospectively from February 2013 to July 2013. The data from the trainee's urban encounters were compared to that of the rural centres. The spectrum of conditions seen in these two settings was placed in the disease categories specified in the Australasian College of Dermatologists ( ACD) curriculum. Results The Royal Adelaide Hospital outpatient experience provided greater exposure to skin neoplasms, lymphoproliferative and myeloproliferative disorders and non-infectious neutrophilic/eosinophilic disorders. The outreach sites provided greater exposure to infections, adnexal diseases and genodermatoses. Both urban and rural experiences provided a broad exposure to the disease categories outlined in the ACD curriculum. Conclusions The spectrum of disease requiring specialist dermatology input varies between urban South Australia and rural NT. The inclusion of dermatology trainees in outreach visits broadens their clinical exposure. It is recommended that other dermatology service providers in Australia consider documenting clinical casemix comparisons to assess dermatology demand, outcomes and trainee exposure. [ABSTRACT FROM AUTHOR]

Objective: To investigate the possible correlation between serum 25-hydroxyvitamin D levels and resistant hypertension (RH).Subjects and Methods: Patients who had undergone ambulatory blood pressure measurements (ABPM) during outpatient controls were enrolled. Fifty subjects with RH, 50 with controlled hypertension (CHT) and 50 normotensive subjects (NT) were included in the study. RH was defined as 'suboptimal blood pressure control despite using 3 antihypertensive agents including a diuretic or need for 4 or more drugs to control blood pressure'. The 25-hydroxyvitamin D and parathormone levels were compared between the groups. Pearson's correlation coefficient test was applied to assess the correlation between 25-hydroxyvitamin D levels and office blood pressure (BP) and ABPM. Logistic regression analysis was used to determine the independent correlates of RH.Results: The 25-hydroxyvitamin D level was significantly lower in the RH group (17.02 ± 5.4 ng/ml) compared to the CHT (24.9 ± 4.8 ng/ml) and NT groups (28.0 ± 5.7 ng/ml, p < 0.001). In univariate correlation analysis, 25-hydroxyvitamin D levels had a significant negative correlation with office systolic BP (r = -0.329, p < 0.001), office diastolic BP (r = -0.395, p < 0.001), systolic ambulatory BP (r = -0.844, p = 0.004), and diastolic ambulatory BP (r = -0.567, p = 0.005). ROC analysis revealed that 25-hydroxyvitamin D levels <21.50 ng/ml predicted the presence of RH with a sensitivity of 78% and a specificity of 79% (AUC = 0.89, 95% CI 0.83-0.94). In the multivariate logistic regression analysis, 25-hydroxyvitamin D level was independently correlated with the presence of RH (β 0.660, 95% CI 0.572-0.760, p < 0.001).Conclusion: There was an independent correlation between lower 25-hydroxyvitamin D levels and presence of RH. [ABSTRACT FROM AUTHOR]

Data about the prevalence of communicable and non-communicable diseases, as one of the most important categories of epidemiological data, is used for interpreting health status of communities. This study aims to calculate the prevalence of outpatient diseases through the characterization of outpatient prescriptions. The data used in this study is collected from 1412 prescriptions for various types of diseases from which we have focused on the identification of ten diseases. In this study, data mining tools are used to identify diseases for which prescriptions are written. In order to evaluate the performances of these methods, we compare the results with Naïve method. Then, combining methods are used to improve the results. Results showed that Support Vector Machine, with an accuracy of 95.32%, shows better performance than the other methods. The result of Naive method, with an accuracy of 67.71%, is 20% worse than Nearest Neighbor method which has the lowest level of accuracy among the other classification algorithms. The results indicate that the implementation of data mining algorithms resulted in a good performance in characterization of outpatient diseases. These results can help to choose appropriate methods for the classification of prescriptions in larger scales. [ABSTRACT FROM AUTHOR]

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

Objectives: Outpatient parenteral antimicrobial therapy (OPAT) is an effective way of treating infections, but complications are common. We identified patient characteristics and OPAT treatment factors associated with increased risk of OPAT-related complications.Methods: We used a retrospective cohort design that assessed 337 adult patients treated with OPAT for orthopedic and neurosurgical infections between August 1, 2008 and May 30, 2010. Independent variables included demographics, infection characteristics, lead time factors, OPAT treatment factors, and comorbid conditions. Multivariable log-binomial regression was used to estimate the risk of OPAT complications.Results: The mean patient age was 55 years (range 19-87), 86% had an orthopedic infection, and 44% were treated with intravenous vancomycin. OPAT complications were seen in 45% (152/337) of the cohort. Risk ratios for OPAT complications were 1.9 (95% confidence interval 1.4-2.5) in patients having no primary care provider, 1.7 (95% confidence interval 1.3-2.1) for those treated with vancomycin.Conclusions: Identifying specific patient characteristics and OPAT treatment factors could facilitate OPAT process improvements to reduce the risk of OPAT complications for vulnerable patients. [ABSTRACT FROM AUTHOR]

Background: Functional endoscopic sinus surgery (FESS) is the mainstay of a therapeutic technique for nasal pathologies. This study is to compare the ability of preoperative dexmedetomidine versus clonidine for producing controlled hypotensive anesthesia during FESS in adults in an ambulatory care setting. Materials and Methods: Sixty patients (25-50 years) posted for ambulatory FESS procedures under general anesthesia were randomly divided into Group C and D (n = 33 each) receiving dexmedetomidine 1 µg/kg and clonidine 1.5 µg/kg, respectively; both diluted in 100 ml saline solution 15 min before anesthetic induction. Nasal bleeding and surgeon's satisfaction score; amount and number of patients receiving fentanyl and nitroglycerine for analgesia and deliberate hypotension, duration of hypotension, post anesthesia care unit (PACU) and hospital stay; hemodynamic parameters and side effects were recorded for each patient. Results: Number and dosage of nitroglycerine used was significantly (P = 0.034 and 0.0001 respectively) lower in Group D compared to that in Group C. Similarly, number of patients requiring fentanyl and dosage of same was significantly lower in Group D. But, the duration of controlled hypotension was almost similar in both the groups. Group D patients suffered from significantly less nasal bleeding and surgeon's satisfaction score was also high in this group. Discharge from PACU was significantly earlier in Group D, but hospital discharge timing was quite comparable among two groups. Intraoperative hemodynamics was significantly lower in Group D (P < 0.05) without any appreciable side effects. Conclusion: Dexmedetomidine found to be providing more effectively controlled hypotension and analgesia, and thus, allowing less nasal bleeding as well as more surgeons' satisfaction score. [ABSTRACT FROM AUTHOR]

The article discusses the results of a surveillance aimed at determining the incidence of healthcare-associated (HA) clostridium difficile infection (CDI) and identifying the characteristics of the C. difficile strains implicated. Findings suggest that the shift to outpatient care for children with less-severe conditions plays a role in the rising rates of CDI.

Background. Outpatient respiratory tract infections are the most common reason for antibiotic prescribing to children. Although prior studies suggest that antibiotic overuse occurs, patient-specific data or data exploring the variability and determinants of variability across practices and practitioners is lacking. Methods. This study was conducted from a retrospective cohort of encounters to 25 diverse pediatric practices with 222 clinicians, from January 1 to December 31, 2009. Diagnoses, medications, comorbid conditions, antibiotic allergy, and demographic data were obtained from a shared electronic health record and validated by manual review. Practice-specific antibiotic prescription and acute respiratory tract infection diagnosis rates were calculated to assess across-practice differences after adjusting for patient demographics and clustering of encounters within clinicians. Results. A total of 102 102 (28%) of 399 793 acute visits by 208 015 patients resulted in antibiotic prescriptions. After adjusting for patient age, sex, race, and insurance type, and excluding encounters by patients with chronic conditions, antibiotic prescribing by practice ranged from 18% to 36% of acute visits, and the proportion of antibiotic prescriptions that were broad-spectrum ranged from 15% to 58% across practices, despite additional exclusion of patients with antibiotic allergies or prior antibiotic use. Diagnosis of (Dx) and broad-spectrum antibiotic prescribing (Broad) for acute otitis media (Dx: 8%-20%; Broad: 18%-60%), sinusitis (Dx: 0.5%-9%; Broad: 12%-78%), Streptococcal pharyngitis (Dx: 1.8%-6.4%; Broad: 2%-30%), and pneumonia (Dx: 0.4%-2%; Broad: 1%-70%) also varied by practice (P < 0.001 for all comparisons). Conclusions. Antibiotic prescribing for common pediatric infections varied substantially across practices. This variability could not be explained by patient-specific factors. These data suggest the need for and provide highimpact targets for outpatient antimicrobial stewardship interventions. [ABSTRACT FROM AUTHOR]

Background: Inappropriate antibiotic prescribing, particularly for respiratory tract infections (RTI) in ambulatory care, has become a worldwide public health threat due to resulting antibiotic resistance. In spite of various interventions and campaigns, wide variations in antibiotic use persist between European countries. Cultural determinants are often referred to as a potential cause, but are rarely defined. To our knowledge, so far no systematic literature review has focused on cultural determinants of antibiotic use. The aim of this study was to identify cultural determinants, on a country-specific level in ambulatory care in Europe, and to describe the influence of culture on antibiotic use, using a framework of cultural dimensions.Method: A computer-based systematic literature review was conducted by two research teams, in France and in Norway. Eligible publications included studies exploring antibiotic use in primary care in at least two European countries based on primary study results, featuring a description of cultural determinants, and published between 1997 and 2015. Quality assessment was conducted independently by two researchers, one in each team, using appropriate checklists according to study design. Each included paper was characterized according to method, countries involved, sampling and main results, and cultural determinants mentioned in each selected paper were extracted, described and categorized. Finally, the influence of Hofstede's cultural dimensions associated with antibiotic consumption within a primary care setting was described.Results: Among 24 eligible papers, 11 were rejected according to exclusion criteria. Overall, 13 papers meeting the quality assessment criteria were included, of which 11 used quantitative methods and two qualitative or mixed methods. The study participants were patients (nine studies) and general practitioners (two studies). This literature review identified various cultural determinants either patient-related (illness perception/behaviour, health-seeking behaviour, previous experience, antibiotic awareness, drug perception, diagnosis labelling, work ethos, perception of practitioner) or practitioner-related (RTI management, initial training, antibiotic awareness, legal issues, practice context) or both (antibiotic awareness).Discussion and Conclusion: Cultural factors should be considered as exerting an ubiquitous influence on all the consecutive stages of the disease process and seem closely linked to education. Interactions between determinant categories, cultural dimensions and antibiotic use in primary care are multiple, complex and require further investigation within overlapping disciplines. The context of European projects seems particularly relevant. [ABSTRACT FROM AUTHOR]

The article discusses the importance of proper patient preparation for blood sampling in terms of adherence to fasting requirements. Topics include the fasting requirements published by the Working Group on Pre-analytical Phase of the European Federation of Clinical Chemistry and Laboratory Medicine (WG-PRE EFLM), how failure to adhere to these requirements lead to laboratory errors, and a recommendation for laboratory specialists to continuously improve the quality of the total testing cycle.

Objectives: Annually, millions of pairs of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) tests are ordered. These enzymes are highly correlated, and ALT is far more specific diagnostically than AST. To reduce AST testing, we suggest measuring AST only when ALT exceeds a predetermined limit. Methods: We derived the proportions of elevated ASTs that would not be measured based on 15 months of paired inpatient and outpatient ALT and AST data. Results: For inpatients, a 35 U/L ALT limit for initiating AST testing would reduce AST testing by 51%, missing only 3% and 7.5% of ASTs exceeding 50 U/L and 35 U/L, respectively. In outpatients, AST testing can be reduced by more than 65%, with fewer missed elevated ASTs (0.5% and 2% of the ASTs exceeding 50 U/L and 35 U/L, respectively). Conclusions: Conservatively, $100 million could be saved annually in the US health care budget by selectively limiting AST testing in just the US outpatient environment. [ABSTRACT FROM AUTHOR]

Surveillance and analyses of unintentional injuries can be used to help prioritise community prevention efforts. This study describes changes in local patterns for unintentional injuries resulting in deaths, hospitalisations, and outpatient visits to health care clinics and emergency rooms, comparing information from two different study periods, 1978 and 2008, in the Swedish communities of Falköping and Lidköping. Injury cases were analysed, and confidence intervals were derived. The study results show that while most injuries decreased comparing the first study period to the second, these changes were only significant in terms of decreases in outpatient care. This study points to the importance of more systematic collection data of injury events treated at the outpatient level, particularly for communities where there are relatively low numbers of injury-related deaths and hospitalisations. [ABSTRACT FROM AUTHOR]

Background: A provider-initiated counselling and testing (PICT) strategy replaced the voluntary counselling and testing (VCT) strategy with respect to the provision of human immunodeficiency virus (HIV) counselling and testing (HCT) in KwaZulu-Natal province with the aim of increasing the uptake of HIV services. VCT depended on clients requesting HCT, whereas HCT is routinely offered to all persons utilising health facilities, regardless of the reason for the visit with the provision of PICT. This study reports on the feasibility and early outcomes of using the PICT strategy in KwaZulu-Natal. Method: Health workers were trained to provide PICT to patients presenting at the outpatient department (OPD) of two public health institutions in KwaZulu-Natal from December 2010 to May 2011. Data on the offering and uptake of HIV services were recorded and analysed using univariate and multivariate analysis to compare HCT uptake and other systematic barriers before and after the introduction of PICT. Results: A significant change in the uptake of HCT after the introduction of PICT at both sites (p = 0.242 and p = 0.224) and in the uptake of HIV testing (p = 0.062 and p = 0.224) was not observed. PICT offering was weakest at the OPDs (p < 0.001), and was solely provided by counsellors (85.5%). Few (29.2%) clients were screened for tuberculosis. Immunological and clinical staging was performed on 29.8% and 1.0% of HIV-positive patients, respectively. The linkage to prevention services was low with 12.2% of clients referred for further care. Conclusion: PICT implementation and integration with other services faces human resource, infrastructural and conceptual barriers, and is not currently feasible at OPDs. The urgent provision of operational guidance and training for providers is needed. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The aim of our study was to assess the interobserver and intraobserver reliability as well as the content and construct validity of the FIGO prolapse assessment scoring system (FASS). Methods: Women with and without (controls) symptoms of pelvic organ prolapse (POP) attending gynaecology outpatient clinics in four different countries were recruited prospectively. Each woman was assessed using the FASS which included: (1) physical examination findings designated with the letter P; (2) presence of symptoms of prolapse, urinary and bowel symptoms designated with the letter S; and (3) assessment of degree of bother designated with the letter B. A scoring system was also developed. For interobserver reliability women were examined by two separate examiners using the FASS. For intraobserver reliability the FASS was repeated by the same examiner within 2 weeks. The interclass correlation coefficient (ICC) was also calculated to assess limits of agreements. Validity was assessed by comparing the FASS scores between symptomatic and asymptomatic women using the Mann-Whitney U test ( p value <0.001). Results: A total of 177 women (98 symptomatic and 79 controls) were recruited. Intraobserver reliability had ICCs between 0.716 and 1. Interobserver reliability had ICCs between 0.795 and 0.909. Domain and total scores were significantly different between symptomatic and asymptomatic women ( p < 0.001, Mann-Whitney U test). There was a good correlation between FASS P scores and POP-Q scores (rho 0.763, p < 0.001). Conclusions: The FIGO prolapse assessment scoring system has good intraobserver and interobserver agreement and has demonstrated both content and construct validity. [ABSTRACT FROM AUTHOR]

Background: Evaluation of patient/client satisfaction with pharmacy services as a crucial part of the health services through appropriate studies is important. This will help identify specific areas of the service which need improvement in realizing high quality pharmacy services in general and enhance the positive changes in the current pharmaceutical services provision in Ethiopia. The current study aimed at assessing the level of client satisfaction with the services of the outpatient pharmacy of Gondar University Referral Hospital (GURH) in northwestern Ethiopia. Methods: An institution-based cross-sectional study was conducted involving 400 clients who had prescriptions/orders filled at the outpatient pharmacy of the hospital during the period of 5th to 25th of November 2013. The data on the level of satisfaction of clients with the services of the outpatient pharmacy in the hospital was collected using a structured interview guide adopted from an instrument translated into Amharic and validated. The data collected was entered into and analyzed using Statistical Packages for Social Sciences (SPSS) version 16. Results: The overall mean score the respondents gave to satisfaction with the pharmaceutical services was 2.48 out of a maximum of 5.00 score. The mean scores for all the individual parameters rated were less than 3.00. Maximum mean scores were given for parameters asking about the promptness of prescription medication service (2.99), and professionalism of the pharmacy staff (2.96) with the lowest being scored for information given to clients about the storage of medication (1.25), and explanations of possible side effects (1.27). Clients who were served free of fee recorded significantly higher level of satisfaction than those who paid. Higher levels of satisfaction were also reported among illiterates, older adults and those with no job compared to those with higher education, merchants and government employees. Conclusions: This study showed that the overall mean satisfaction level of clients of the outpatient pharmacy was low and it differed among different socio-demographic characteristics. Further research in to the reasons behind the low satisfaction should be done to provide appropriate solutions to improve the service. [ABSTRACT FROM AUTHOR]

It remains unclear whether prediction of violence based on historical factors can be improved by adding dynamic risks, protective strengths, selection of person-specific key strengths or critical vulnerabilities, and structured professional judgment (SPJ). We examine this in outpatient forensic psychiatry with the Short-Term Assessment of Risk and Treatability (START) at 3 and 6 months follow-up. An incident occurred during 33 (13%) out of 252 3-month and 44 (21%) out of 211 6-month follow-up periods (n = 188 unique clients). Pearson correlations for all predictor variables were in the expected directions. Prediction of recidivism based on historical factor ratings (odds ratio [OR] = 1.10) could not be improved through the addition of dynamic risk, protective strength, or key or critical factor scores (all ORs ns). The addition of the SPJ improved the model to modest accuracy (area under the curve [AUC] = .64) but made no independent significant contribution (OR = 1.55, p = .21) for the 3-month follow-up. For the 6-month follow-up, SPJ scores also increased predictive accuracy to modest (AUC = .67) and made a significant independent contribution to the prediction of the outcome (OR = 1.98, p = .04). Multicollinearity limits were unviolated. Limitations apply, however, results are similar to those from clinical, researcher rated samples and are discussed in the light of setting specific characteristics. Although it is too early to advocate implementing risk assessment instruments in clinical practice, we can conclude that clinicians in a heterogeneous outpatient forensic psychiatric setting can achieve similar results with the START as clinicians and research staff in more homogeneous inpatient settings. [ABSTRACT FROM AUTHOR]

The rapid growth of urgent care facilities (UCFs) and other types of convenient care centers has largely been attributed to increasing consumer demand for more convenient and affordable healthcare. UCFs typically treat non-emergency, acute conditions and are increasingly serving as an alternative to "traditional" care settings, such as physician offices and emergency departments (EDs). A study was conducted to characterize geographic variation in both utilization and charges for common lab tests, office visits, and flu vaccines by care settings. Based on claims data from FAIR Health's National Private Insurance Claims (FH NPIC®) database, the results suggest that utilization and charge patterns for common procedures vary significantly by care setting across geographic region and over time but the variations are generally small in magnitude. For example, across geographic regions, charges for the flu vaccine are found to be higher when performed in a physician's office in contrast to being performed in a UCF. [ABSTRACT FROM AUTHOR]

Long-term assessment of ambulatory behavior and joint motion are valuable tools for the evaluation of therapy effectiveness in patients with neuromuscular disorders and gait abnormalities. Even though there are several tools available to quantify ambulatory behavior in a home environment, reliable measurement of joint motion is still limited to laboratory tests. The aim of this study was to develop and evaluate a novel inertial sensor system for ambulatory behavior and joint motion measurement in the everyday environment. An algorithm for behavior classification, step detection, and knee angle calculation was developed. The validation protocol consisted of simulated daily activities in a laboratory environment. The tests were performed with ten healthy subjects and eleven patients with multiple sclerosis. Activity classification showed comparable performance to commercially available activPAL sensors. Step detection with our sensor system was more accurate. The calculated flexion-extension angle of the knee joint showed a root mean square error of less than 5° compared with results obtained using an electro-mechanical goniometer. This new system combines ambulatory behavior assessment and knee angle measurement for long-term measurement periods in a home environment. The wearable sensor system demonstrated high validity for behavior classification and knee joint angle measurement in a laboratory setting. [ABSTRACT FROM AUTHOR]

Background Intensive treatment options are lacking for patients with severe skin disease recalcitrant to outpatient therapy. The availability of inpatient dermatology care has almost disappeared in many parts of the United States. One possible solution for this is a day treatment center for patients with severe dermatologic disease recalcitrant to outpatient therapy. Methods Descriptive study based on retrospective medical record review of all patients attending the day hospital for treatment in 2010. We collected data on patient demographics, distribution of admission diagnosis, treatments used, and length of stay. Results A total of 211 patients had 235 admissions. Mean age was 57.7 years (range 3.8-92.1 years). The most common indications for admission were dermatitis (139 admissions [59.2%]), psoriasis (58 [24.7%]), and mycosis fungoides (eight [3.4%]). The main treatment interventions were wet dressings (195 admissions [83.0%]) and Goeckerman treatment (38 [16.2%]). The median number of days of treatment was three (interquartile range, 2-5 days) for wet dressings and 22 days (interquartile range, 21-24 days) for Goeckerman therapy. Conclusions The dermatology day treatment center provided intensive skin-directed therapy and filled a critical practice gap in the management of our patients with severe widespread skin diseases recalcitrant to outpatient therapy. We propose that the dermatology day treatment center is a valuable model that could be considered by both private practitioners and academic centers in the United States as an important adjunct to fill the gap in availability of intensive topical treatments for patients with severe skin disease. [ABSTRACT FROM AUTHOR]

Objective To assess the impact of Massachusetts Health Reform ( MHR) on access, quality, and costs of outpatient care for the already-insured. Data Sources/Study Setting Medicare data from before (2006) and after (2009) MHR implementation. Study Design We performed a retrospective difference-in-differences analysis of quantity of outpatient visits, proportion of outpatient quality metrics met, and costs of care for Medicare patients with ≥1 chronic disease in 2006 versus 2009. We used the remaining states in New England as controls. Data Collection/Extraction Methods We used existing Medicare claims data provided by the Centers for Medicare and Medicaid Services. Principal Findings MHR was not associated with a decrease in outpatient visits per year compared to controls (9.4 prereform to 9.6 postreform in MA vs. 9.4-9.5 in controls, p = .32). Quality of care in MA improved more than controls for hemoglobin A1c monitoring, mammography, and influenza vaccination, and similarly to controls for diabetic eye examination, colon cancer screening, and pneumococcal vaccination. Average costs for patients in Massachusetts increased from $9,389 to $10,668, versus $8,375 to $9,114 in control states ( p < .001). Conclusions MHR was not associated with worsening in access or quality of outpatient care for the already-insured, and it had modest effects on costs. This has implications for other states expanding insurance coverage under the Affordable Care Act. [ABSTRACT FROM AUTHOR]

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

Background: Improving the patient experience is a key focus within the National Health Service. This has led us to consider how health services are experienced, from both staff and patient perspectives. Novel service improvement activities bring staff and patients together to use design-led methods to improve how health services are delivered. The Multiple Sclerosis Outpatient Future Group study aimed to explore how analogies and props can be used to facilitate rich interactions between staff and patients within these activities. This paper will consider how these interactions supported participants to share experiences, generate ideas and suggest service improvements. Method: Qualitative explorative study using 'future groups,' a reinterpretation of the recognised focus groups method directed towards exploring future alternatives through employing analogies and physical props to engage participants to speculate about future service interactions and health experiences. Participants were people with multiple sclerosis (PwMS) and outpatient staff: staff nurses, nursing assistants, junior sisters and reception staff. Results: Use of future groups, analogies and physical props enabled PwMS and outpatient staff to invest their own ideas and feelings in the service improvement activity and envisage alternative health care scenarios. The combination of participants in the groups with their diverse perspectives and knowledge of the service led to a collaborative approach in which staff highlighted potential practical problems and patients ensured ideas were holistic. Service improvements were prototyped and tested in the outpatient clinic. Conclusion: Design-led methods such as future groups using analogies and physical props can be used to facilitate interactions between staff and patients in service improvement activities, leading to the generation of meaningful ideas. It is hoped that improving the quality of ideation tools within design-led methods can contribute to developing successful service interventions in service improvement activities. [ABSTRACT FROM AUTHOR]

Background: The causes of severe morbidity in health facilities implementing Antiretroviral Treatment (ART) programmes are poorly documented in sub-Saharan Africa. We aimed to describe severe morbidity among HIV-infected patients after ART initiation, based on data from an active surveillance system established within a network of specialized care facilities in West African cities. Methods: Within the International epidemiological Database to Evaluate AIDS (IeDEA)-West Africa collaboration, we conducted a prospective, multicenter data collection that involved two facilities in Abidjan, Côte d'Ivoire and one in Cotonou, Benin. Among HIV-infected adults receiving ART, events were recorded using a standardized form. A simple case-definition of severe morbidity (death, hospitalization, fever > 38°5C, Karnofsky index < 70%) was used at any patient contact point. Then a physician confirmed and classified the event as WHO stage 3 or 4 according to the WHO clinical classification or as degree 3 or 4 of the ANRS scale. Results: From December 2009 to December 2011, 978 adults (71% women, median age 39 years) presented with 1449 severe events. The main diagnoses were: non-AIDS-defining infections (33%), AIDS-defining illnesses (33%), suspected adverse drug reactions (7%), other illnesses (4%) and syndromic diagnoses (16%). The most common specific diagnoses were: malaria (25%), pneumonia (13%) and tuberculosis (8%). The diagnoses were reported as syndromic in one out of five events recorded during this study. Conclusions: This study highlights the ongoing importance of conventional infectious diseases among severe morbid events occurring in patients on ART in ambulatory HIV care facilities in West Africa. Meanwhile, additional studies are needed due to the undiagnosed aspect of severe morbidity in substantial proportion. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to explore the association between resistance and outpatient antibiotic use, expressed as either DDDs per 1000 inhabitants per day (DID) or packages per 1000 inhabitants per day (PID). Methods: IMS Health data on outpatient penicillin and cephalosporin (β-lactam) and tetracycline, macrolide, lincosamide and streptogramin (TMLS) use, aggregated at the level of the active substance (WHO version 2011) expressed as DID and PID (2000-07) were linked to European Antimicrobial Resistance Surveillance System (EARSS) data on proportions of penicillin-non-susceptible Streptococcus pneumoniae (PNSP) and erythromycin-non-susceptible S. pneumoniae (ENSP) (2000-09). Combined data for 27 European countries were analysed with a generalized linear mixed model. Model fit for use in DID, PID or both and 0, 1 or 2 year time lags between use and resistance was assessed and predictions of resistance were made for decreasing use expressed as DID, PID or both. Results: When exploring the association between β-lactam use and PNSP, the best model fit was obtained for use in PID without time lag. For the association between TMLS use and ENSP, the best model fit was obtained for use in both PID and DID with a 1 year time lag. PNSP and ENSP are predicted to decrease when use decreases in PID, but not when use decreases in DID. Conclusions: Associations between outpatient antibiotic use and resistance and predictions of resistance were inconsistent whether expressing antibiotic use as DID or PID. We recommend that data on antibiotic use be expressed as PID and that time lags between use and resistance be considered when exploring these associations. [ABSTRACT FROM AUTHOR]

Background Advanced care directives (ACDs) and end-oflife discussions are important and typically difficult to initiate because of the sensitive nature of the topic and competing clinical priorities. Resident physicians need to have these conversations but often do not in their continuity clinics. Objective We implemented a program to (1) increase physician opportunity to discuss end-of-life wishes with their patients, and (2) improve residents' confidence in leading discussions regarding ACDs. Intervention A total of 95 residents in an academic outpatient internal medicine resident continuity clinic participated in a formalized curriculum (didactic sessions, simulations, and academic detailing). Clinic workflow alterations prompted the staff to question if patients had an ACD or living will, and then cued residents to discuss these issues with the patients if they did not. Results Of the 77% of patients who were asked about ACDs, 74% had no ACD but were interested in discussing this topic. After our intervention, 65% (62 of 95) of our residents reported having at least 1 outpatient discussion with their patients. Residents reported increased confidence directing and discussing advanced care planning with older patients and conducting a family meeting (P < .01). Conclusions By delivering a formalized curriculum and creating a clinical environment that supports such discussions, resident physicians had more ACD discussions with their patients and reported increased confidence. When provided information and opportunity, patients consistently expressed interest in talking with their physician about their advanced care wishes. [ABSTRACT FROM AUTHOR]

In this article a person-centered/experiential (PCE) approach of group therapeutic treatment for borderline clients in out-patient and day treatment is described. First, we focus on client-centered views on borderline processes. Then, we look at the general directives that are distilled from different borderline-focused treatment models to investigate to what extent these directives can be assimilated in a PCE approach. Next, we argue for a group therapeutic approach where possible and describe the selection criteria for participation. The core of this article describes the group process from the viewpoint of a client-centered/experiential and interpersonal orientation. A number of important processes and interventions are described according to the three main phases distinguished in the treatment process (beginning, middle and termination phase). These phases varyingly come to the fore in relation to changes in group composition. Typical borderline processes and challenges for the group therapist are illustrated with clinical vignettes. [ABSTRACT FROM PUBLISHER]

The article discusses research on the role of highly sensitive cardiac troponin I (cTnI) assay in identifying candidates for out-of-hospital treatment of acute pulmonary embolism (PE). Topics covered include the assay as a screening tool for right ventricular injury caused by PE, the in-hospital hemodynamic instability and death in normotensive acute PE patients, and the implementation of cTnI as a pivotal risk stratification tool.

Background The role of adjunct systemic corticosteroid therapy in children with community-acquired pneumonia (CAP) is not known. The objective was to determine the association between adjunct systemic corticosteroid therapy and treatment failure in children who received antibiotics for treatment of CAP in the outpatient setting. Methods The study included a retrospective cohort study of children, aged 1–18 years, with a diagnosis of CAP who were managed at an outpatient practice affiliated with Geisinger Health System from January 1, 2008 to January 31, 2010. The primary exposure was the receipt of adjunct corticosteroid therapy. The primary outcome was treatment failure defined as a respiratory-associated follow-up within 14 days of diagnosis in which the participant received a change in antibiotic therapy. The probability of receiving adjunct systemic corticosteroid therapy was calculated using a matched propensity score. A multivariable conditional logistic regression model was used to estimate the association between adjunct corticosteroids and treatment failure. Results Of 2244 children with CAP, 293 (13%) received adjunct corticosteroids, 517 (23%) had underlying asthma, and 624 (28%) presented with wheezing. Most patients received macrolide monotherapy for their CAP diagnosis (n = 1329; 59%). Overall, treatment failure was not associated with adjunct corticosteroid treatment (odds ratio [OR], 1.72; 95% confidence interval [CI], 0.93 and 3.19), but the association was statistically significant among patients with no history of asthma (OR, 2.38; 95% CI, 1.03 and 5.52), with no statistical association among patients with a history of asthma. Conclusion Adjunct corticosteroid therapy was associated with treatment failure among children diagnosed with CAP who did not have underlying asthma. [ABSTRACT FROM PUBLISHER]

Objectives: To investigate the determinants of the length of hospitalization (LOH) due to acute odontogenic maxillofacial infections (AOMIs) from 2009 to 2013. Materials and Methods: Dental records of adult patients with AOMIs and related data were retrieved from the Vilnius University's dental hospital. The LOH was related to several determinants in each of the following domains: outpatient primary care, severity of AOMIs, lifestyle and disease domains. Determinants were also associated with the LOH using multivariate analysis. Results: A total of 285 patients were hospitalized with AOMIs, of which 166 (58.2%) were males and 119 (41.8%) were females. The mean LOH was 8.3 ± 4.9 days. The bivariate analysis did not reveal any statistically significant differences in LOH between patients with AOMIs who received urgent outpatient primary care and those who did not receive such care prior to hospitalization. All AOMI severity-related determinants were associated with the LOH. The LOH was related to coexisting systemic conditions but not to the higher severity of dental or periodontal diseases. Both bivariate and multivariate analyses revealed similar trends, where the most significant determinants of a longer LOH were related to the severity of AOMIs. Conclusion: The most important determinants regarding longer hospitalization were indicators of infection severity such as an extension of the odontogenic infection and the need for an extraoral incision to drain the infection. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

OBJECTIVE To assess the change in level of diabetes quality management in primary care groups and outpatient clinics after feedback and tailored support. RESEARCH DESIGN AND METHODS This before-and-after study with a 1-year follow-up surveyed quality managers on six domains of quality management. Questionnaires measured organization of care, multidisciplinary teamwork, patient centeredness, performance results, quality improvement policy, and management strategies (score range 0-100%). Based on the scores, responders received feedback and a benchmark and were granted access to a toolbox of quality improvement instruments. If requested, additional support in improving quality management was available, consisting of an elucidating phone call or a visit from an experienced consultant. After 1 year, the level of quality management was measured again. RESULTS Of the initially 60 participating care groups, 51 completed the study. The total quality management score improved from 59.8% (95% CI 57.0-62.6%) to 65.1% (62.8-67.5%; P < 0.0001). The same applied to all six domains. The feedback and benchmark improved the total quality management score (P = 0.001). Of the 44 participating outpatient clinics, 28 completed the study. Their total score changed from 65.7% (CI 60.3-71.1%) to 67.3% (CI 62.9-71.7%; P = 0.30). Only the results in the domain multidisciplinary teamwork improved (P = 0.001). CONCLUSIONS Measuring quality management and providing feedback and a benchmark improves the level of quality management in care groups but not in outpatient clinics. The questionnaires might also be a useful asset for other diabetes care groups, such as Accountable Care Organizations. [ABSTRACT FROM AUTHOR]