Models of intensive care unit follow-up care and feasibility of intervention delivery: A systematic review

BACKGROUND

The optimal model of outpatient intensive care unit (ICU) follow-up care remains uncertain, and there is limited evidence of benefit.

RESEARCH QUESTION

The objective of this research is to describe existing models of outpatient ICU follow-up care, quantify participant recruitment and retention, and describe facilitators of patient engagement.

STUDY DESIGN & METHODS

A systematic search of the MEDLINE and EMBASE databases was undertaken in June 2021. Two independent reviewers screened titles, abstracts, and full texts against eligibility criteria. Studies of adults with any outpatient ICU follow-up were included. Studies were excluded if published before 1990, not published in English, or of paediatric patients. Quantitative data were extracted using predefined data fields. Key themes were extracted from qualitative studies. Risk of bias was assessed.

RESULTS

A total of 531 studies were screened. Forty-seven studies (32 quantitative and 15 qualitative studies) with a total of 5998 participants were included. Of 33 quantitative study interventions, the most frequently reported model of care was in-person hospital-based interventions (n = 27), with 10 hybrid (part in-hospital, part remote) interventions. Literature was limited for interventions without hospital attendance (n = 6), including telehealth and diaries. The median ranges of rates of recruitment, rates of intervention delivery, and retention to outcome assessment for hospital-based interventions were 51.5% [24-94%], 61.9% [8-100%], and 52% [8.1-82%], respectively. Rates were higher for interventions without hospital attendance: 82.6% [60-100%], 68.5% [59-89%], and 75% [54-100%]. Facilitators of engagement included patient-perceived value of follow-up, continuity of care, intervention accessibility and flexibility, and follow-up design. Studies had a moderate risk of bias.

INTERPRETATION

Models of post-ICU care without in-person attendance at the index hospital potentially have higher rates of recruitment, intervention delivery success, and increased participant retention when compared to hospital-based interventions.

PROSPERO REGISTRATION

CRD42021260279.

Prescription of Long-Acting Injectable Antipsychotic Medications Among Outpatient Mental Health Care Service Providers

OBJECTIVE

Long-acting injectable antipsychotic medications (LAIAPs) are a valuable and underused treatment for patients with chronic mental illnesses such as schizophrenia and bipolar disorder. This study aimed to examine prescription patterns of LAIAPs among outpatient mental health care service providers in the United States.

METHODS

The authors conducted a secondary analysis of the 2020-2021 National Mental Health Services Survey to assess the percentage of outpatient mental health care service providers (N=9,433) that prescribed LAIAPs to patients. Descriptive statistics were calculated to describe the overall frequency of outpatient facilities prescribing LAIAPs and differences in the specific LAIAPs prescribed. The authors also conducted multivariable analyses to identify facility characteristics associated with likelihood of LAIAP prescribing.

RESULTS

Across all outpatient mental health care service providers, 30.6% prescribed LAIAPs. Community mental health centers were most likely to prescribe LAIAPs (62.6%), whereas partial hospitalization and day programs were least likely (32.1%). The most used LAIAP was paliperidone palmitate (77.7%), and the least used was olanzapine pamoate (29.6%). Providers with programs specifically for patients with serious mental illness (59.5%) and providers with a dedicated first-episode psychosis program (58.2%) were more likely to prescribe LAIAPs than were providers without such programming.

CONCLUSIONS

Prescription of LAIAPs is limited at outpatient mental health care service providers in the United States. Expansion of these services and diversification of delivery models are needed to improve LAIAP prescriptions, which are associated with improved patient outcomes across a broad range of measures.

Low availability, long wait times, and high geographic disparity of psychiatric outpatient care in the US

OBJECTIVE

To identify potential barriers to care, this study examined the general psychiatry outpatient new appointment availability in the US, including in-person and telepsychiatry appointments, comparing results between insurance types (Medicaid vs. private insurance), states, and urbanization levels.

METHOD

This mystery shopper study investigated 5 US states selected according to Mental Health America Adult Ranking and geography to represent the US mental health care system. Clinics across five selected states were stratified sampled by county urbanization levels. Calls were made during 05/2022-07/2022. Collected data included contact information accuracy, appointment availability, wait time (days), and related information.

RESULTS

Altogether, 948 psychiatrists were sampled in New York, California, North Dakota, Virginia, and Wyoming. Overall contact information accuracy averaged 85.3%. Altogether, 18.5% of psychiatrists were available to see new patients with a significantly longer wait time for in-person than telepsychiatry appointments (median = 67.0 days vs median = 43.0 days, p < 0.01). The most frequent reason for unavailability was provider not taking new patients (53.9%). Mental health resources were unevenly distributed, favoring urban areas.

CONCLUSION

Psychiatric care has been severely restricted in the US with low accessibility and long wait times. Transitioning to telepsychiatry represents a potential solution for rural disparities in access.

An innovative model of access and triage to reduce waiting in an outpatient epilepsy clinic: an intervention study

BACKGROUND

Delayed access to outpatient care may negatively impact on health outcomes. We aimed to evaluate implementation of the Specific Timely Appointments for Triage (STAT) model of access in an epilepsy clinic to reduce a long waitlist and waiting time.

METHODS

This study is an intervention study using pre-post comparison and an interrupted time series analysis to measure the effect of implementation of the STAT model to an epilepsy clinic. Data were collected over 28 months to observe the number of patients on the waitlist and the waiting time over three time periods: 12 months prior to implementation of STAT, ten months during implementation and six months post-intervention. STAT combines one-off backlog reduction with responsive scheduling that protects time for new appointments based on historical data. The primary outcomes were the number of patients on the waitlist and the waiting time across the three time periods. Secondary outcomes evaluated pre- and post-intervention changes in number of appointments offered weekly, non-arrival and discharge rates.

RESULTS

A total of 938 patients were offered a first appointment over the study period. The long waitlist was almost eliminated, reducing from 616 during the pre-intervention period to 11 post-intervention (p = 0.002), but the hypothesis that waiting time would decrease was not supported. The interrupted time series analysis indicated a temporary increase in waiting time during the implementation period but no significant change in slope or level in the post- compared to the pre-intervention period. Direct comparison of the cohort of patients seen in the pre- and post-intervention periods suggested an increase in median waiting time following the intervention (34 [IQR 25-86] to 46 [IQR 36-61] days (p = 0.001)), but the interquartile range reduced indicating less variability in days waited and more timely access for the longest waiters.

CONCLUSIONS

The STAT model was implemented in a specialist epilepsy outpatient clinic and reduced a large waitlist. Reductions in the waitlist were achieved with little or no increase in waiting time. The STAT model provides a framework for an alternative way to operate outpatient clinics that can help to ensure that all people referred are offered an appointment in a timely manner.

Levels of health literacy among people living with HIV in outpatient care: a cross-sectional study from Denmark

BACKGROUND

Low health literacy (HL) among people living with HIV (PLWHIV) encounter more disease related complications, more difficulty understanding health-related information and low adherence. Considering that, the HL levels among PLWHIV needs to be further investigated. The objective of this study was to investigate the levels of HL and patient involvement among PLWHIV in an outpatient clinic in Denmark. A second objective was to examine differences in HL levels across socio-demographic characteristics.

METHODS

In 2019, a population of 682 PLWHIV from a Danish outpatient hospital clinic were enrolled in cross-sectional study. Patients who had a digital postbox received an electronic questionnaire including following domains; health literacy, patient involvement, and socio-demographic status. Health literacy was measured using the Health Literacy Questionnaire (HLQ) through scores on three subscales: social support for health (HLQ4), engaging with healthcare providers (HLQ6), and understanding health information (HLQ9). An unpaired t-test was used to investigate mean differences in the HLQ scores across socio-demographic variables.

RESULTS

A total of 338 (55%) patients responded to the questionnaire. The included participants demonstrated high levels of HLQ4 (mean = 4.2) and HLQ6 (mean = 4.2), but lower for HLQ9 (mean = 2.9). In total 70-80% reported being involved in decisions about their health. We found a positive association between high level of HL (HLQ9) and living with a partner and higher levels of HL (HLQ4, HLQ6, and HLQ9) and employment.

CONCLUSION

PLWHIV in a Danish out-patient care population were found to have high levels of HL despite differences in demographic characteristics. Further research is needed to examine the levels of HL among non-responders to develop HL approaches and strategies to meet the needs of individuals with different HL skills.

Nonvenereal Infections in Spanish Dermatology Clinics: Results of the DIADERM Study

BACKGROUND AND OBJECTIVE

The burden of nonvenereal infections in Spanish dermatology practice has not yet been evaluated. The aim of this study was to analyze the overall weight of these infections in outpatient dermatology caseloads.

MATERIAL AND METHODS

Observational cross-sectional study of diagnoses made by a random selection of dermatologists from the Spanish Association of Dermatology and Venereology (AEDV) working in outpatient dermatology clinics. The data were obtained through the anonymous DIADERM survey. Diagnoses of infectious diseases were selected using codes from the International Classification of Diseases, Tenth Revision. After excluding sexually transmitted infections, the diagnoses were classified into 22 groups.

RESULTS

Spanish dermatologists diagnosed an estimated 16 190 (95% CI, 9338-23 042) nonvenereal infections on average per week, a figure that accounted for 9.33% of the dermatology caseload. The most common diagnostic groups were nonanogenital viral warts (7475 diagnoses, 46.17% of nonvenereal infections), dermatophytosis (3336, 20.61%), and other viral infections (1592, 9.84%), which included Molluscum contagiosum infections. Nonvenereal infections were more common than noninfectious dermatologic conditions in private clinics (P < .0020) and adults (P <.00001). Patients with these infections were also more likely to be discharged than those with other conditions in both public (P < .0004) and private (P < .0002) practices.

CONCLUSIONS

Nonvenereal infections are frequent in dermatology. They are the third most common reason for outpatient visits, behind actinic keratosis and nonmelanoma skin cancer. By enhancing the participation of dermatologists in the management of skin infections and encouraging interactions with other specialists, we will be able to carve out a niche in an area we have scarcely ventured into to date.

Nonvenereal Infections in Spanish Dermatology Clinics: Results of the DIADERM Study

BACKGROUND AND OBJECTIVE

The burden of nonvenereal infections in Spanish dermatology practice has not yet been evaluated. The aim of this study was to analyze the overall weight of these infections in outpatient dermatology caseloads.

MATERIAL AND METHODS

Observational cross-sectional study of diagnoses made by a random selection of dermatologists from the Spanish Association of Dermatology and Venereology (AEDV) working in outpatient dermatology clinics. The data were obtained through the anonymous DIADERM survey. Diagnoses of infectious diseases were selected using codes from the International Classification of Diseases, Tenth Revision. After excluding sexually transmitted infections, the diagnoses were classified into 22 groups.

RESULTS

Spanish dermatologists diagnosed an estimated 16 190 (95% CI, 9338-23 042) nonvenereal infections on average per week, a figure that accounted for 9.33% of the dermatology caseload. The most common diagnostic groups were nonanogenital viral warts (7475 diagnoses, 46.17% of nonvenereal infections), dermatophytosis (3336, 20.61%), and other viral infections (1592, 9.84%), which included Molluscum contagiosum infections. Nonvenereal infections were more common than noninfectious dermatologic conditions in private clinics (P < .0020) and adults (P <.00001). Patients with these infections were also more likely to be discharged than those with other conditions in both public (P < .0004) and private (P < .0002) practices.

CONCLUSIONS

Nonvenereal infections are frequent in dermatology. They are the third most common reason for outpatient visits, behind actinic keratosis and nonmelanoma skin cancer. By enhancing the participation of dermatologists in the management of skin infections and encouraging interactions with other specialists, we will be able to carve out a niche in an area we have scarcely ventured into to date.

Antibiotic associated diarrhea in outpatient pediatric antibiotic therapy

BACKGROUND

Antibiotic-associated diarrhea is one of the most frequent side effects of antimicrobial therapy. We assessed the epidemiological data of antibiotic-associated diarrhea in pediatric patients in our region.

METHODS

The prospective multi-center study included pediatric patients who were initiated an oral antibiotic course in outpatient clinics and followed in a well-established surveillance system. This follow-up system constituded inclusion of patient by the primary physician, supply of family follow-up charts to the family, passing the demographics and clinical information of patient to the Primary Investigator Centre, and a close telephone follow-up of patients for a period of eight weeks by the Primary Investigator Centre.

RESULTS

A result of 758 cases were recruited in the analysis which had a frequency of 10.4% antibiotic-associated diarrhea. Among the cases treated with amoxicillin-clavulanate 10.4%, and cephalosporins 14.4% presented with antibiotic-associated diarrhea. In the analysis of antibiotic-associated diarrhea occurrence according to different geographical regions of Turkey, antibiotic-associated diarrhea episodes differed significantly (p = 0.014), particularly higher in The Eastern Anatolia and Southeastern Anatolia. Though most commonly encountered with cephalosporin use, antibiotic-associated diarrhea is not a frequent side effect.

CONCLUSION

This study on pediatric antibiotic-associated diarrhea displayed epidemiological data and the differences geographically in our region.

Closing the Gap: The Role of Discharge Nurses in an Emergency Department

INTRODUCTION

Patients discharged from the emergency department may require a follow-up appointment with an outpatient specialty clinic. Referral processes vary by clinic, some requiring faxed referrals, some providing appointments immediately, and others contacting the patients directly. The frequency with which patients are successfully connected with outpatient follow-up services is largely unknown.

METHODS

The ED discharge nurse role was developed to facilitate the navigation of patient follow-up and confirm that patients successfully connect with specialty outpatient clinics. Eight emergency nurses were recruited into this position to study the problem using a quality improvement approach. The ED discharge nurses reviewed referrals, contacted clinics and patients discharged from the emergency department, and intervened when barriers to transition occurred.

RESULTS

The ED discharge nurses were able to determine specific causes and themes of missed appointments experienced by patients. Systemic problems identified include lost faxes, illegible contact information, incomplete referrals, and referral refusals by the clinics without patient notification. Considering the variability of clinic processes outside the emergency department's control, the ED discharge nurse role became crucial in minimizing the risk of lost/unsuccessful follow-up for patients discharged from the emergency department.

DISCUSSION

Implementing the ED discharge nurse role created a contact for outpatient clinic referrals, patient inquiry, and a process to track errors and data to better understand the frequency of missed follow-up. In this quality improvement initiative, the role of the ED discharge nurse addressed the risk of patients falling through the cracks of a complex system.

Client Racial Composition in First-Episode Psychosis Programs Compared With Compositions in Program Service Areas

OBJECTIVE

The authors examined the extent to which clients served by first-episode psychosis programs reflected the racial composition of the surrounding service area and, to the extent that they did not, explored possible explanatory factors.

METHODS

As part of a national study of coordinated specialty care (CSC) sites in the United States, 35 programs documented race for 772 clients. Programs identified a geographic service area for their clients. Using Census data, the authors identified the proportion of clients in this service area who were Black and then examined the extent of disproportionality, calculated as a risk ratio and as a relative difference in racial composition between CSC programs and their service areas.

RESULTS

Overall, 71% of CSC programs had a disproportionately greater proportion of Black clients than Black residents within the service area. This disproportionality was still evident after conducting sensitivity analyses that included adjusting for sampling error in the service area population estimates; however, smaller study sites displayed greater fluctuations in disproportionality in the sensitivity analyses.

CONCLUSIONS

Using data from diverse CSC programs, the authors illustrate that the odds of Blacks receiving services through a CSC program are much higher than would be expected on the basis of the population living in the area being served by the program. Multiple reasons may explain this finding, but in the absence of clear explanatory factors, this result may be ripe for discussion and further investigation.

A simulation-based continuing professional development course for the first 5 minutes of cardiac arrest in the resource-limited local clinics

PURPOSE

Using simulation in continuing professional development (CPD) courses for local practitioners is uncommon in Korea. The aim of our study was to evaluate the responses of the local practitioners for a simulation-based short CPD course.

METHODS

Following the targeted needs assessment of local practitioners, we developed and implemented a 3-hour simulation-based CPD course for the first 5 minutes of cardiac arrest in the resource-limited local clinics. We evaluated the participant's responses to the course using a questionnaire.

RESULTS

During the 3-year implementation period, 115 practitioners participated in 10 courses, and 113 (98%) responded to the questionnaire. The overall course satisfaction (10-point scale) was very positive (10 in 93 [82.3%], 9 in 19 [16.8%], and 8 in 1 [0.8%]). The level (5-point scale) of recommendation to the others was also high (5 in 103 [91.2%] and 4 in 10 [8.8%]). Many participants positively commented on the authentic practical experience of the uncommon crisis in their contexts.

CONCLUSION

A simulation-based short CPD course for in-hospital cardiac arrest could provide an authentic practical experience for local practitioners working in resource-limited clinics.

"They make a difference": a qualitative study of providers' experiences of peer support in outpatient clinics for people living with HIV

BACKGROUND

Although the life expectancy of people living with HIV has increased, they are still often disconnected from society through stigma and discrimination. Peer support has been found to increase social support. Given the limited research on peer support from the providers' perspective, this study explored how peer supporters experience their roles and contributions in outpatient clinics (OPCs). Additionally, healthcare professionals' perceptions of working with peer supporters in OPCs were examined.  METHODS: This qualitative study included purposively selected peer supporters (n = 10) and healthcare professionals (n = 5) from five OPCs in Norway in 2020. In-depth interviews and focus group discussions were conducted in Norwegian or English, using interview guides. Interview transcripts were analysed in NVivo 12 using reflexive and collaborative thematic analysis.

RESULTS

The results show that peer supporters experience mutual support through emotional and honest interactions. Further, the peer supporters found it essential to negotiate with the service users about their preconception of HIV, confront their views through dialogue, and replicate positive experiences by being credible role models. The participants expressed that integrating peer support in the OPCs' usual care processes increased the prospect of equitable services. Quality of peer support and role clarity were identified as critical components. The results demonstrate that emotional and honest conversations promote support between peers and that peer supporters identify a need for a reframed understanding of HIV by modelling plausible alternative interpretations and coping experiences.

CONCLUSIONS

This study contributes to knowledge on how peer support can meet the needs of people living with HIV. Incorporating people living with HIV in the co-production and distribution of healthcare services may improve the knowledge and perspectives in healthcare services. However, the skill standards of peer supporters should be addressed when implementing peer support in usual care.

Behavioral Health Integration in Community Health Centers and Emergency Department Use

Medicaid enrollees with behavioral health disorders often experience fragmented care, leading to high rates of preventable use of emergency departments (EDs). As part of its Medicaid Transformation Program, the Washington Health Care Authority partnered with regional accountable communities of health to collect data on behavioral health integration in community health centers. Clinics who participated in the integrated care demonstration received technical and financial support to increase capacity for integration. This column describes results from an analysis that linked clinic surveys to Medicaid claims to explore characteristics of highly integrated clinics and assess whether clinic capacity for behavioral health integration is associated with ED visit frequency.

Knowledge, safety, and teamwork: a qualitative study on the experiences of anaesthesiologists and nurse anaesthetists working in the preanaesthesia assessment clinic

Background

The preanaesthesia assessment clinic (PAC) has been shown to contribute to safe anaesthesia assessment in hospitals. In the PAC, patients are assessed with an interview and can also ask relevant questions about anaesthesia. The intention is to ensure that patients are comprehensively prepared for the surgery and hospital stay. Although earlier studies have assessed the effects of PAC, attitudes and satisfaction of the healthcare personnel working in PAC remain unknown. Thus, this study aimed to examine the experiences of anaesthesiologists and nurse anaesthetists working in PACs as well as to explore barriers and facilitators in this context.

Methods

A descriptive qualitative approach was used to explore the experiences of anaesthesiologists and nurse anaesthetists working in PACs. Thirteen semi-structured interviews were conducted using face-to-face, telephone, or digital platforms in five hospitals in west, south, and north Norway between 2020 and 2021. The interviews were transcribed and thematically analysed according to Braun and Clarke’s six-steps semantic reflexive analysis.

Results

Four themes and nine subthemes were identified through an active analysis process, including developing competence in clinical anaesthesia practice, identifying barriers and facilitators influencing collaboration and teamwork, improving patient safety and outcomes through structured assessment, and identifying other organisational factors affecting the delivery of healthcare to surgical patients.

Conclusions

Working in the PAC contributed to competence development among the personnel. Additionally, teamwork was considered important for the proper functioning of the PAC. Patient safety was perceived as improved owning to the structured assessment in PAC, with patients getting the opportunity to improve their knowledge and being more involved in the upcoming anaesthesia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01852-w.

Enhanced Adoption of Measurement-Based Care in a Psychiatry Outpatient Clinic After High-Reliability Process Changes

OBJECTIVE

This study examined the impact of high-reliability changes to how measurement-based care questionnaires were administered to patients on rates of questionnaire completion.

METHODS

Medical record data were abstracted from 44,305 adult outpatient return visits to a psychiatry outpatient clinic within two 10-month periods (before and after process changes were implemented). Linear mixed models tested the change in questionnaire completion rates and the interaction effects between time and age, sex, and race.

RESULTS

Patient completion of questionnaires increased by 79% after process changes. Women were more likely to complete questionnaires regardless of the process. After process changes, older patients and White patients were more likely to complete questionnaires.

CONCLUSIONS

High-reliability process changes to measurement-based care questionnaire administration were associated with higher questionnaire completion rates. Racial, age, and sex disparities in questionnaire completion rates were notable and deserve attention in future measurement-based care implementation efforts.

Differences in Services Offered by Certified Community Behavioral Health Clinics and Community Mental Health Centers

OBJECTIVE

This study examined differences between certified community behavioral health clinics (CCBHCs) and community mental health centers (CMHCs) in the services offered and populations served.

METHODS

Data from the 2020 National Mental Health Services Survey were used to quantify the proportion of CCBHCs (N=336) and CMHCs (N=1,953) that offered services and served populations described in the CCBHC certification criteria.

RESULTS

A higher proportion of CCBHCs than CMHCs offered crisis services, peer support, substance use disorder treatment, treatment for co-occurring disorders, antipsychotics, assertive community treatment, general medical health screening, tobacco cessation services, psychiatric rehabilitation services, and other outpatient services. A higher proportion of CCBHCs than CMHCs served veterans and transition-age youths.

CONCLUSIONS

CCBHCs differed from CMHCs in the services provided and populations served. Differences between CCBHCs and CMHCs in some service categories were more pronounced in demonstration than in nondemonstration states. However, it was unclear whether these differences existed before the introduction of the CCBHC model.

Peer support in an outpatient clinic for people living with human immunodeficiency virus: a qualitative study of service users' experiences

BACKGROUND

Although human immunodeficiency virus (HIV) has become a manageable condition with increasing life expectancy, people living with HIV (PLHIV) are still often isolated from society due to stigma and discrimination. Peer support provides one avenue for increased social support. Given the limited research on peer support from the perspective of PLHIV, this study explored their experiences of peer support organised by healthcare professionals in an outpatient clinical setting.

METHODS

The study used a qualitative, descriptive research design for an in-depth understanding of peer support provided to PLHIV in the context of outpatient clinics. Healthcare professionals contributed to the recruitment of 16 participants. We conducted in-depth interviews about participants' experiences of peer support, and performed a directed content analysis of the data. Further, we sorted the data into pre-determined categories.

RESULTS

The pre-determined categories constituted attachment, social integration, an opportunity for nurturance, reassurance of worth, reliable alliance, and guidance. The identified themes were: gained emotional support, disclosure behaviour allowed garnering of emotional support, non-disclosure promoted the need to meet a peer, experienced a sense of belonging, activated an opportunity for mutual support, means to re-establish belief in one's own worth, perceived a positive affirmation of disease management, facilitated dialogue about disease management, the outpatient clinic as a safe place, and a setting for flexible, individualised support.

CONCLUSIONS

This study highlights the peer support experiences of PLHIV in the context of outpatient clinics. The participants' experiences align with previous findings, showing that peer support contributes to mutual emotional support between peers. This is particularly important in cultures of non-disclosure where PLHIV experience intersectional stigma. Additionally, our results show outpatient clinics to be supportive surroundings for facilitating peer support, ensuring confidentiality in peer support outreach. Therefore, peer support contributes positively to individualising outpatient clinic services to meet the changing needs of PLHIV.

Today's referral is tomorrow's repeat patient: referrals to and between medical outpatient clinics in a hospital

Background

Unnecessary referrals in Danish hospitals may be contributing to inefficient use of health services already stretched and under pressure and may lead to delayed treatment for patients. Despite a growing awareness in the literature and in practice of issues related to referrals, there has been relatively little research on referrals between specialists in hospital outpatient clinics and how it can be improved. This study aimed to describe the referral patterns to and within the Medical Department at the University Hospital of Southern Denmark. The Medical Department consists of the following medical specialist outpatient clinics; nephrology, pulmonology, endocrinology, cardiovascular, wound outpatient clinic, and a day hospital.

Methods

Two specialist physicians assessed all referrals to the medical specialist outpatient clinics over one month (from 01 September 2019 to 30 September 2019) using data drawn from the Danish electronic patient record system (Cosmic). Data on referral pattern, and patient age and sex, were statistically analysed to identify and characterise patterns of referral.

Results

Four hundred seventy-one (100%) referrals were included in the study. 49.5% (233) of the referrals were from the hospital and 50.5% (238) from general practitioners (GPs). Of the 233 referrals from the hospitals, 31% (72) were from the Medical Department.

Conclusion

The high rate of referrals (31%) from own Medical Department or outpatient clinics may reflect an inefficient internal referral process within the department. Improved collaboration between specialists could have the potential to improve health outcomes, timely access to care and more appropriate healthcare resource utilisation.

What is the impact of specialist palliative care outpatient consultations on pain in adult patients with cancer? A systematic review

PURPOSE

The aim of this systematic review was to determine the impact of specialist palliative care (SPC) consultations in outpatient settings on pain control in adults suffering from cancer.

METHODS

Systematic Review. Databases CINAHL, Medline, PsychInfo, and Embase were searched in February 2021. Relevant studies were also hand-searched and gray literature was searched in February 2021. The PICO mnemonic (Population, Intervention, Comparison, and Outcome) was used to form the review question. Of 1053 potential studies identified, 10 met the inclusion criteria. Quality appraisal of included studies was conducted using the evidence-based librarian (EBL) critical appraisal checklist.

RESULTS

Outcome data from 56% (n = 5/9) studies indicated a non-statistically significant reduction in pain. Narrative analysis of the remaining studies indicated a statistically significant reduction in pain in 50% (n = 2/4) of the studies, one study showed mixed results, and one study found no statistically significant improvement in pain control. In relation to secondary outcomes, results from 33% (3/9) of studies indicated statistically significant improvement in symptom control. Data from 22% (n = 2/9) of studies indicated no statistically significant improvement in the symptoms measured. Narrative analysis of the remaining four studies indicated generally mixed results. EBL scores of included studies ranged between 50% and 95.23%.

CONCLUSION

Outpatient SPC consultations may have a positive impact on the control of pain and other distressing symptoms for cancer patients, however, results show mixed effects. Given that it is unclear what it is about outpatient SPC that impacts positively or otherwise on pain and symptom control.

Rapid Telepsychiatry Implementation During COVID-19: Increased Attendance at the Largest Health System in the United States

OBJECTIVE

This study aimed to examine differences in completion rates between telepsychiatry and in-person visits during the COVID-19 pandemic and a prior reference period.

METHODS

The authors used electronic medical record data along with chi-squared or t tests to compare patients' demographic characteristics. Generalized estimating equations for estimating the odds of primary and secondary outcomes were used, controlling for demographic characteristics.

RESULTS

During COVID-19, the odds of completing a telepsychiatry visit (N=26,715) were 6.68 times the odds of completing an in-person visit (N=11,094). The odds of completing a telepsychiatry visit during COVID-19 were 3.00 times the odds of completing an in-person visit during the pre-COVID-19 reference period (N=40,318).

CONCLUSIONS

In this cross-sectional study, outpatient adult mental health clinic telepsychiatry appointments, largely by telephone, were strongly associated with a higher rate of visit completion compared with in-person visits during and prior to the COVID-19 pandemic. Regulators should consider permanently enabling reimbursement for telephone-only telepsychiatry visits.

What Proportion of the Spanish Dermatology Caseload Corresponds to Primarily Sexually Transmitted Infections and Other Anogenital Dermatoses? Results From the DIADERM National Random Survey

BACKGROUND AND OBJECTIVE

Predominantly sexually transmitted infections (PSTIs) and infestations and other anogenital dermatoses are covered in the training of specialists in dermatology and venereology in Spain. This study aimed to analyze the proportion of the dermatology caseload these diseases account for within the Spanish national health service and private practices.

MATERIAL AND METHODS

Observational cross-sectional study of 2 periods. We described the diagnoses made in outpatient dermatology clinics obtained through the anonymous DIADERM survey of a representative random sample of dermatologists. Codes of the International Classification of Diseases, Tenth Revision, were used to select all 36 relevant diagnoses in the 2 periods. The diagnoses were classified into 12 groups.

RESULTS

Only 3.16% of diagnoses corresponded to PSTIs and other anogenital dermatoses. The most common diagnostic group was anogenital human papillomavirus infection, followed by molluscum contagiosum infestation, and inflammatory anogenital dermatoses. Lesions with these diagnoses were usually the main reasons for first visits in the national health service. In private practice, the diagnoses usually came after referrals from other physicians.

CONCLUSIONS

PSTIs and other anogenital dermatoses account for a very small proportion of the dermatology caseload in Spain, even considering that diagnoses of molluscum contagiosum inflate the overall estimate of such conditions. The failure to include centers specializing in PSTIs in the DIADERM random sample of dermatologists partly explains the survey's underestimation of these diseases in the specialty. A clear effort to promote use of specialized clinics should be made.

Are missed appointments in an outpatient clinic for adults with congenital heart disease the harbinger for care gaps?

AIMS

Life-long follow-up is vital for patients with congenital heart disease (CHD) to safeguard longevity. Missing scheduled appointments might be prodromal to subsequent care gaps, but our understanding of their occurrence and impact is limited. This study determined the occurrence and predictors of missed appointments (MA), assess its predictive value for care gaps, and explored if MA or care gaps are associated with increased mortality.

METHODS AND RESULTS

From 2007 to 2009, the occurrence of MA in 2075 CHD patients was documented at an adult CHD clinic. The frequency of outpatient visits in 1363 adults with moderate to complex CHD was calculated from 2009 to 2012. Patients without a visit were considered to have a care gap. Data on mortality were collected from 2013 to 2017. Missed appointments occurred in 11% of patients and were more common in men [odds ratio (OR) = 1.57; 95% confidence interval (CI): 1.18-2.08], without a history of cardiac procedures (OR = 1.46; 95% CI: 1.08-1.97), and for morning visits (OR = 1.45; 95% CI: 1.10-1.92). Care gaps were identified in 6% of moderate to complex CHD. A MA was significantly associated with an increased likelihood of care gaps (OR = 19.55; 95% CI: 11.92-32.07; R2 = 26.5%). In moderate to complex CHD, no difference in mortality rates was related to the occurrence of discontinued care.

CONCLUSION

The occurrence of MA was related to patients' gender, no history of cardiac interventions, and time of day of the outpatient visits. Care gaps were associated by the preceding MA. No association with increased mortality rates was observed. Interventions reducing missed appointments, such as SMS-reminders prior to visits, need investigation.

Remote consultations in paediatric urology-Not just for pandemics?

Although some centres have successfully integrated remote clinics into their paediatric urological practice, for many, remote clinics have developed due to the COVID-19 pandemic. One UK-based institution has integrated remote clinics in their practice for over two years and has developed guidelines considering which conditions may be suitable for remote consultations. These guidelines have been appraised by the European Association of Urology Young Academic Urologists paediatric working group. Through practical experience and anticipated difficulties, we have discussed considerations that paediatric urology departments should ponder when integrating remote clinics into their practice as we move forward from the pandemic.

Factors contributing to satisfaction with care in cancer outpatients

OBJECTIVES

To evaluate satisfaction with care (SC) in cancer patients treated at a Spanish day hospital, to identify determinants of SC, and to assess the association between SC and quality of life (QL).

METHODS

Cross-sectional study in which 119 patients undergoing outpatient chemotherapy completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the Cancer Outpatient Satisfaction with Care questionnaire for chemotherapy (OUT-PATSAT35 CT), and an item on loyalty. Bivariate correlations between each subscale of the OUT-PATSAT35 CT and overall satisfaction, and between the subscales of OUT-PATSAT35 CT and QLQ-C30, were calculated. Multiple linear regression models were used to analyze determinants of patients' SC.

RESULTS

Mean age was 62.5 years (SD 11.7), and 54.6% of the sample were female. Mean scores for SC were > 75 out of 100 on all OUT-PATSAT35 CT subscales, except environment. Overall satisfaction was higher than satisfaction in any subscale, and all patients would choose the same day hospital again. Correlation with overall satisfaction was moderate but statistically significant for all subscales. Patients treated for tumor recurrence and those undergoing palliative treatment manifested significantly lower overall satisfaction. Correlation between the EORTC QLQ-C30 and the OUT-PATSAT35 CT was not statistically significant, although patients with better health status reported higher satisfaction in several subscales.

CONCLUSION

Patient-reported SC and loyalty towards the day hospital were high. Disease evolution and aim of treatment were determinants of overall satisfaction. The correlation between SC and QL was unclear. Some areas for improving care were noted.

Resuming Breast Imaging Services in the Aftermath of the COVID-19 Pandemic: Safety and Beyond

As the Coronavirus disease 2019 (COVID-19) epidemic begins to stabilize, different medical imaging facilities not directly involved in the COVID-19 epidemic face the dilemma of how to return to regular operation. We hereby discuss various fields of concern in resuming breast imaging services. We examine the concerns for resuming functions of breast imaging services in 2 broad categories, including safety aspects of operating a breast clinic and addressing potential modifications needed in managing common clinical scenarios in the COVID-19 aftermath. Using a stepwise approach in harmony with the relative states of the epidemic, health care system capacity, and the current state of performing breast surgeries (and in compliance with the recommended surgical guidelines) can ensure avoiding pointless procedures and ensure a smooth transition to a fully operational breast imaging facility.

End-user perceptions of a patient- and family-centred intervention to improve nutrition intake among oncology patients: a descriptive qualitative analysis

Background

People with cancer are at high risk of malnutrition. Nutrition education is an effective strategy to improve patient outcomes, however, little is known regarding the impact of family and/or carer involvement in nutrition education and requires investigation. The purpose of the study was to evaluate PIcNIC (Partnering with families to promote nutrition in cancer care) intervention acceptability from the perspective of patients, families and health care providers.

Methods

A descriptive qualitative study was undertaken at an inpatient and an outpatient hospital setting in Australia and an outpatient/home setting in Hong Kong. A patient-and-family centred intervention including nutrition education, goals setting/nutrition plans, and food diaries, was delivered to patients and/or families in the inpatient, outpatient or home setting. Semi-structured interviews were used to explore perceptions of the intervention. 64 participants were interviewed; 20 patients, 15 family members, and 29 health care professionals. Data were analysed using deductive and inductive content analysis.

Results

Two categories were identified; 1) ‘context and intervention acceptability’; and 2) ‘benefits of patient- and family-centred nutrition care’. Within each category redundant concepts were identified. For category 1 the redundant concepts were: the intervention works in outpatient settings, the food diary is easy but needs to be tailored, the information booklet is a good resource, and the intervention should be delivered by a dietitian, but could be delivered by a nurse. The redundant concepts for category 2 were: a personalised nutrition plan is required, patient and family involvement in the intervention is valued and the intervention has benefits for patients and families. Converging and diverging perceptions across participant groups and settings were identified.

Conclusions

In this paper we have described an acceptable patient- and family-centred nutrition intervention, which may be effective in increasing patient and family engagement in nutrition care and may result in improved nutrition intakes. Our study highlights important contextual considerations for nutrition education; the outpatient and home setting are optimal for engaging patients and families in learning opportunities.

Physicians' perspective on shared decision-making in Dubai: a cross-sectional study

BACKGROUND

Shared decision-making (SDM) is an integral part of patient-centered delivery of care. Maximizing the opportunity of patients to participate in decisions related to their health is an expectation in care delivery nowadays. The purpose of this study is to explore the perceptions of physicians in regard to SDM in a large private hospital network in Dubai, United Arab Emirates.

METHODS

This study utilized a cross-sectional design, where a survey questionnaire was assembled to capture quantitative and qualitative data on the perception of physicians in relation to SDM. The survey instrument included three sections: the first solicited physicians' personal and professional information, the second entailed a 9-item SDM Questionnaire (SDM-Q-9), and the third included an open-ended section. Statistical analysis assessed whether the average SDM-Q-9 score differed significantly by gender, age, years of experience, professional status-generalist versus specialist, and work location-hospitals versus polyclinics. Non-parametric analysis (two independent variables) with the Mann-Whitney test was utilized. The qualitative data was thematically analyzed.

RESULTS

Fifty physicians from various specialties participated in this study (25 of each gender-85% response rate). Although the quantitative data analysis revealed that most physicians (80%) rated themselves quite highly when it comes to SDM, qualitative analysis underscored a number of barriers that limited the opportunity for SDM. Analysis identified four themes that influence the acceptability of SDM, namely physician-specific (where the physicians' extent of adopting SDM is related to their own belief system and their perception that the presence of evidence negates the need for SDM), patient-related (e.g., patients' unwillingness to be involved in decisions concerning their health), contextual/environmental (e.g., sociocultural impediments), and relational (the information asymmetry and the power gradient that influence how the physician and patient relate to one another).

CONCLUSIONS

SDM and evidence-based management (EBM) are not mutually exclusive. Professional learning and development programs targeting caregivers should focus on the consolidation of the two perspectives. We encourage healthcare managers and leaders to translate declared policies into actionable initiatives supporting patient-centered care. This could be achieved through the dedication of the necessary resources that would enable SDM, and the development of interventions that are designed both to improve health literacy and to educate patients on their rights.

Follow-up of liver transplant recipients

The number of surviving liver allograft recipients is increasing almost exponentially. The quality and length of life is increasing but most recipients have reduced survival and quality of life compared with healthy matched individuals. Causes of premature death include cardio and cerebrovascular disease, renal failure, graft failure, de novo malignancy and recurrent disease. Follow-up is needed lifelong to ensure graft and patient health and ensure that complications are recognised and treated early. Immunosuppression is kept to the appropriate minimum and prophylactic interventions are given early, such as use of statins and tight control of blood pressure and blood sugar. Recipients will require life-long follow-up, and this is placing an increasing burden on transplant units. Follow-up is best done by close collaboration between the Liver Transplant Unit, the local hospital and primary care team. Involvement of other health care practitioners, such as recipient coordinators, pharmacists, dermatologists and addiction specialists may improve outcomes. Key to successful follow-up are agreed protocols and good communication between the recipients and all relevant health care providers. Use of IT allows for better communication and will support use of video and telephone consultations in selected instances. The most appropriate follow-up will depend on many factors, including logistic and geographic issues, local experience. The provision of well-funded and supported registries at local, national and international levels will allow for improvements in management.

Specific timely appointments for triage to reduce wait times in a medical outpatient clinic: protocol of a pre-post study with process evaluation

Background

Managing demand for services is a problem in many areas of healthcare, including specialist medical outpatient clinics. Some of these clinics have long waiting lists with variation in access for referred people. A model of triage and appointment allocation has been developed and tested that has reduced waiting times by about a third in community outpatient services. This study aims to determine whether the model can be applied in the setting of a specialist medical outpatient clinic to reduce wait time from referral to first appointment.

Methods

A pre-post study will collect data before and after implementing the Specific Timely Appointments for Triage (STAT) model of access and triage. The study will incorporate a pre-implementation period of 12 months, an implementation period of up to 6 months and a post STAT-implementation period of 6 months. The setting will be the epilepsy clinic at a metropolitan health service in Melbourne. Included will be all people referred to the clinic, or currently waiting, during the allocated periods of data collection (total sample estimated n = 975). Data routinely collected by the health service and qualitative data from staff will be analysed to determine the effects of introducing the STAT model. The primary outcome will be wait time, measured by number of patients on the wait list at monthly time points and the mean number of days waited from referral to first appointment. Secondary outcomes will include patient outcomes, such as admission to hospital while waiting, and service outcomes, including rate of discharge. Analysis of the primary outcome will include interrupted time series analysis and simple comparisons of the pre and post-implementation periods. Process evaluation will include investigation of the fidelity of the intervention, adaptations required and qualitative analysis of the experiences of clinic staff.

Discussion

Prompt access to service and optimum patient flow is important for patients and service providers. Testing the STAT model in a specialist medical outpatient clinic will add to the evidence informing service providers and policy makers about how the active management of supply and demand in health care can influence wait times. The results from this study may be applicable to other specialist medical outpatient clinics, potentially improving access to care for many people.

Analysis of patients shared in consultations of internal medicine and other medical specialties

BACKGROUND AND OBJECTIVE

The aging population is resulting in an increasing number of patients with multiple diseases that require treatment by various specialties. We examined the evolution of consultations and of the percentage of patients treated by several medical specialties.

METHODS

We analysed internal medicine (IM) consultations and those of other medical specialties in a hospital during 1997, 2007 and 2017 for the general population and for those older than 65 years.

RESULTS

Over the course of 20 years, the rate of first IM consultations per 1000 inhabitants increased 44%, and that of other medical specialties increased 137%. The percentage of patients seen by more than one specialty went from 13.8% in 1997 to 32.6% in 2017 and reached 45.5% for those older than 65 years.

CONCLUSIONS

The care for populations with growing comorbidity has a major impact on health systems and requires organisational changes for their care.

[Assessment of the effectiveness of an intervention to improve immunization coverage in splenectomy patients]

OBJECTIVE

Splenectomized patients have an increased risk of sepsis caused by encapsulated bacteria. Pneumococcal, meningococcal and Haemophilus influenzae B vaccination is recommended in this group. The aim of our study was to assess the impact of the introduction of an immunization hospital clinic on their immunization coverages.

METHODS

Quasi-experimental study. The control group included patients splenectomized between January 2012-April 2014, and the intervention group included patients splenectomized between May 2014-December 2016. The global and specific immunization coverages were compared between both groups using a Chi-square test.

RESULTS

80 patients were analyzed. The most commonly administered vaccine was the 23-valent pneumococcal polysaccharide vaccine (65.0%). A significant improvement was observed both in the global immunization rate (17.1% in the pre-intervention study vs. 57.8% in the post-intervention study) (RR: 3.37; 95% CI: 1.56-7.27) and in the specific immunization rate for the Haemophilus influenzae B, meningococcal C and 13-valent pneumococcal conjugate vaccines.

CONCLUSIONS

Introducing an immunization hospital clinic is an effective measure to improve the immunization coverage of splenectomy patients.

Testing the leadership and organizational change for implementation (LOCI) intervention in Norwegian mental health clinics: a stepped-wedge cluster randomized design study protocol

BACKGROUND

Alignment across levels of leadership within an organization is needed for successful implementation of evidence-based practice. The leadership and organizational change for implementation (LOCI) intervention is a multi-faceted multilevel implementation strategy focusing on enhancing first-level general and implementation leadership while also engaging with organization upper management to develop an organizational climate for implementation. The aim of the project is to evaluate the effectiveness of LOCI in supporting the implementation of evidence-based treatment for PTSD in child- and adult-specialized mental health clinics in health trusts in Norway.

METHODS

The study design is a stepped-wedge cluster randomized trial with enrollment of clinics in three cohorts. Executives, clinic leaders, and therapists will be asked to complete surveys assessing leadership and implementation climate. Surveys will be completed at baseline, 4, 8, 12, 16, and 20 months. Results from surveys will be shared with executives and clinic leaders to inform the subsequent creation of tailored leadership and climate development plans for enhanced implementation. Patients will complete surveys measuring traumatic events and post-traumatic stress symptoms during the therapy process. Therapy sessions will be audio or video recorded and scored for fidelity as part of training.

DISCUSSION

This study aims to provide knowledge on how to improve leadership and organizational climate to enhance effective implementation of evidence-based treatments in mental health services.

TRIAL REGISTRATION

The study has been registrated in ClinicalTrials with ID NCT03719651 .

Metabolic Syndrome at an Outpatient Clinic for Bipolar Disorders: A Case for Systematic Somatic Monitoring

OBJECTIVES

The primary objective of the study was to determine whether the Monitoring Outcomes of Psychiatric Pharmacotherapy (MOPHAR) program improved somatic monitoring practices at an outpatient clinic for bipolar disorders in the Netherlands. The secondary objective was to determine in MOPHAR the frequency of metabolic syndrome (compared with its measurability before MOPHAR) and treatment thereof.

METHODS

Frequencies of physical examinations and laboratory tests before (retrospectively) and after (prospectively) the active introduction of MOPHAR were compared among adult patients (N=155).

RESULTS

A median of three measurements (range 0-19) per patient were performed before MOPHAR, compared with 24 measurements (range 3-24) after MOPHAR (p<0.001). MOPHAR revealed somatic abnormalities previously unknown to treating physicians. Metabolic syndrome was present in 53% of patients; of these, 98% were not known to have metabolic syndrome before MOPHAR.

CONCLUSIONS

Introducing a monitoring program largely improved knowledge regarding metabolic abnormalities, which are frequently present among patients with bipolar disorder.

On the Very, Very Frontlines of Mental Health Care

The role and training needs of client-facing administrative staff in mental health settings is an underidentified topic in the literature. Although interactions between the medical office staff and clients are not typically defined as therapeutic, patients nevertheless often view client-facing staff as an extension of their physician or care team. These interactions can be both meaningful and important to the overall care experience and should be conceptualized and understood as a legitimate part of the larger healing environment. To this end, the authors propose that a more fulsome understanding is needed of the experiences and impact of administrative staff's role in the larger clinical encounter from the perspectives of both clients and staff. The authors also identify a number of unmet training and support needs for client-facing administrative staff.

The correlation between the quality of life and clinical variables among outpatients with schizophrenia

The study identifies the correlation between the quality of life (QoL) among outpatients with schizophrenia and clinical outcomes. A cross-sectional study design was used with 157 people with schizophrenia treated in outpatient clinics. Demographic, clinical and psychosocial variables were examined for their influence on QoL. Data were analysed with descriptive statistics, Pearson product moment correlation and stepwise forward multiple linear regression. The majority of the study participants were female, single, unemployed, had secondary level of education or less and were being supported financially by family members. QoL correlated negatively with advanced age, male gender, longer duration of illness, high body mass index and prescribed typical anti-psychotic medication. However, it was related positively with employment and being married. Illness duration, recurrent hospitalisation, knowledge level about schizophrenia, psychiatric symptoms and coping mechanisms were found to be key significant predictors of QoL among participants. The study findings enhance our understanding of socio-demographic, clinical and psychosocial characteristics influencing the QoL in people with schizophrenia. Involvement of families in the management process may improve patients' ability to be integrated in the community and be more socially active.

Community-Academic Partnership: Establishing the Institute for Mental Health Research Early Psychosis Intervention Center

Growing evidence suggests that specialized, multicomponent intervention provided early in the course of a psychotic disorder may have a positive effect in ameliorating the morbidity and mortality associated with these disorders. This column describes the development of the Institute for Mental Health Research Early Psychosis Intervention Center, which leverages the unique strengths of a community and academic partnership to provide such specialty care in a youth-friendly, stigma-free environment. Since it opened in 2016, the program has had numerous successes, including securing increased reimbursements rates and performance-based incentives for the treatment of first-episode psychosis.

[Absenteeism and associated factors in scheduled visits to a Preventive Medicine outpatient clinic]

BACKGROUND

Patient absenteeism in outpatient clinics represents a significant obstacle to the cost-effectiveness of healthcare. The aim of this study was to assess the frequency of absence of patients and its associated factors in scheduled visits to a Preventive Medicine department.

PATIENTS AND METHODS

The cross-sectional study was carried out in the Service of Preventive Medicine of the Lozano Blesa University Clinical Hospital of Zaragoza. It included all the visits scheduled from 3 January to 31 March 2017. For each visit, the date and time were registered, together with the type (first or consecutive appointments), age, gender, town of residence, country of birth, and underlying disease. The Chi-squared test was used to determine the association between the variables and making the visit, with a multiple logistic regression analysis being performed on the variables in which a significant association was found.

RESULTS

Of the total of 582 appointments studied, the absenteeism rate was 12.5% (73 out of 582; 13.7% for first appointments and 11.7% for consecutive appointments). Variables that revealed a significant association with patients not attending were: time (9.00-11:15 a. m.; OR=1.84; 95%CI: 1.10-3.08), day of the week (Mondays-Thursdays; OR=3.19; 95%CI: 1.12-9.07), country of birth (outside of Spain; OR=2.09; 95%CI:1.09-3.99), vaccination group (chronic kidney disease during pre-dialysis or dialysis; OR=3.59; 95%CI: 1.57-8.18), and age group (under 52 years old; OR=1.85; 95%CI: 1.08-3.19).

CONCLUSIONS

The rate of absenteeism is at an intermediate position compared to the outpatient visits for other departments. The detection of associated factors makes it possible to plan specific measures for improvements that may reduce absences.

Assessment of oral anticoagulation control at two pharmacist-managed clinics in Brazil

Background Warfarin remains widely used by patients with cardiovascular diseases. When using warfarin, the quality of oral anticoagulation control is a critical determinant to minimize the risk of bleeding and thromboembolic events. Pharmacist engagement in patient care is relevant towards improving the quality of warfarin therapy. Objective To assess the quality of oral anticoagulation control measured by time in therapeutic range (TTR) at two pharmacist-managed anticoagulation clinics (AC). Method This study included adults with indication of continuous warfarin use. Patients were recruited at two AC of public hospitals in Brazil (2014-2015). Anticoagulation control was assessed by TTR using the Rosendaal method. Laboratory INR values were collected for the maximum period of follow-up (2009-2015). Results A total of 554 patients were studied. The median age was 63.7 [Quartile 1 (Q1) 54.3; Quartile 3 (Q3) 73.6] years, 57.4% female. The median TTR was 64.3% [Q1 54.0%; Q3 74.0%], and 344 (61.6%) patients had TTR ≥ 60%. Conclusion Pharmacist-managed AC have achieved an adequate TTR in Brazilian patients with low socioeconomic status. Interventions include face-to-face appointments for individual patient education, warfarin-dosing adjustments and monitoring of drug interactions. Pharmacists are important to improve adherence and the quality of warfarin therapy in low- and middle income countries.

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

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

Home-Based Outpatient Telepsychiatry to Improve Adherence With Treatment Appointments: A Pilot Study

OBJECTIVE

This study examined whether patients who had been nonadherent with outpatient appointments and who were randomly assigned to receive treatment through a telepsychiatry intervention (home-based video teleconferencing) would show improvement in adherence to appointments, compared with a treatment-as-usual group.

METHODS

Participants (N=22) were randomly assigned to home-based video teleconferencing or to outpatient treatment as usual during a six-month study. The primary outcome measure was improvement in visit adherence, which was analyzed using a two-sample t test.

RESULTS

Percentage improvement in visit adherence did not differ significantly between the telepsychiatry and treatment-as-usual groups (14%, compared with 15%). A greater number of participants in the telepsychiatry group reported less subjective difficulty in keeping appointments.

CONCLUSIONS

A small number of participants, short study period, selection bias, and the Hawthorne effect may have limited measured impact in this study. The findings implied that visit nonadherence among frequently nonadherent individuals is largely unrelated to inconvenience.

Beyond "Med Management"

Today, outpatient psychiatric care is commonly referred to as "medication management" and is often delivered in 15- to 20-minute visits by psychiatric care providers who receive little workflow support from technology or medical assistants. This Open Forum argues that this current state of psychiatric care delivery is a problem, comments on how psychiatry got here, and suggests that, through reframing and redesign, psychiatric professionals can improve care for those delivering and for those receiving this needed service.

ANMCO/SIC Consensus Document: cardiology networks for outpatient heart failure care

Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics.

The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals.

The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment.

In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services.

What should be the appropriate minimal duration for patient examination and evaluation in pulmonary outpatient clinics?

INTRODUCTION

Patient examinations performed in a limited time period may lead to impairment in patient and physician relationship, defective and erroneous diagnosis, inappropriate prescriptions, less common use of preventive medicine practices, poor patient satisfaction, and increased violent acts against health-care staff.

OBJECTIVE

This study aimed to determine the appropriate minimal duration of patient examination in the pulmonary practice.

METHODS

A total of 49 researchers from ten different study groups of the Turkish Thoracic Society participated in the study. The researchers were asked to examine patients in an almost ideal manner, without time constraint under available conditions.

RESULTS

A total of 1680 patient examinations were reviewed. The mean duration of patient examination in ideal conditions was determined to be 20.4 ± 9.6 min. Among all steps of patient examination, the longest time was spent for "taking medical history." The total time spent for patient examination was statistically significantly longer in the university hospitals than in the governmental hospitals and training and research hospitals (P < 0.001). Among different patient categories, the patients with a chronic disorder presenting for the first time and were referred from primary or secondary to tertiary care for further evaluation have required the longest time for patient examination.

CONCLUSION

According to our study, the appropriate minimal duration for patient examination is 20 min. It has been observed that in university hospitals and in patients with chronic pulmonary diseases, this duration has been increased to above 25 min. The durations in clinical practice should be planned accordingly.

Enhancing outpatient clinics management software by reducing patients' waiting time

The Kingdom of Saudi Arabia (KSA) gives great attention to improving the quality of services provided by health care sectors including outpatient clinics. One of the main drawbacks in outpatient clinics is long waiting time for patients-which affects the level of patient satisfaction and the quality of services. This article addresses this problem by studying the Outpatient Management Software (OMS) and proposing solutions to reduce waiting times. Many hospitals around the world apply solutions to overcome the problem of long waiting times in outpatient clinics such as hospitals in the USA, China, Sri Lanka, and Taiwan. These clinics have succeeded in reducing wait times by 15%, 78%, 60% and 50%, respectively. Such solutions depend mainly on adding more human resources or changing some business or management policies. The solutions presented in this article reduce waiting times by enhancing the software used to manage outpatient clinics services. Both quantitative and qualitative methods have been used to understand current OMS and examine level of patient's satisfaction. Five main problems that may cause high or unmeasured waiting time have been identified: appointment type, ticket numbering, doctor late arrival, early arriving patient and patients' distribution list. These problems have been mapped to the corresponding OMS components. Solutions to the above problems have been introduced and evaluated analytically or by simulation experiments. Evaluation of the results shows a reduction in patient waiting time. When late doctor arrival issues are solved, this can reduce the clinic service time by up to 20%. However, solutions for early arriving patients reduces 53.3% of vital time, 20% of the clinic time and overall 30.3% of the total waiting time. Finally, well patient-distribution lists make improvements by 54.2%. Improvements introduced to the patients' waiting time will consequently affect patients' satisfaction and improve the quality of health care services.

Outpatient clinic waiting time, provider communication styles and satisfaction with healthcare in India

Purpose - The purpose of this paper is to evaluate the impact of extended waiting time on patients' perceptions of provider communication skills and in-clinic satisfaction, in three major cities in India. Design/methodology/approach - In total, 625 patients were interviewed. The multivariate general linear model was used to determine the causality and relationship between the independent and the dependent variable. A moderation analysis was also conducted to assess waiting time role as a potential moderator in doctor-patient communication. Findings - Results show that patients with higher waiting time were less satisfied with health care quality. Male patients and patients of male providers were more affected by extended waiting time than female patients and patients of female providers. The advanced regression analysis, however, suggests weak support for waiting time and its effect on overall satisfaction with clinic quality. Waiting time did not moderate the relationship between satisfaction with dominant communication style, and overall satisfaction at the outpatient clinic. Research limitations/implications - A cross-sectional study does not easily lend itself to explaining causality with certainty. Thus, sophisticated techniques, such as structural equation modelling may also be utilized to assess the influence of extended waiting time on satisfaction with healthcare at outpatient clinics. Practical implications - Findings are relevant for providers as the onus is on them to ensure patient satisfaction. They should initiate a workable waiting time assessment model at the operational level. Originality/value - There has been a relatively lesser focus on patient waiting time in patient-provider satisfaction studies. In India, this aspect is still vastly unexplored especially in the context of outpatient clinics. Gender wise pattern of patient satisfaction and waiting time is also missing in most studies.

Effects of structured written feedback by cards on medical students' performance at Mini Clinical Evaluation Exercise (Mini-CEX) in an outpatient clinic

INTRODUCTION

Feedback cards are recommended as a feasible tool for structured written feedback delivery in clinical education while effectiveness of this tool on the medical students' performance is still questionable.  The purpose of this study was to compare the effects of structured written feedback by cards as well as verbal feedback versus verbal feedback alone on the clinical performance of medical students at the Mini Clinical Evaluation Exercise (Mini-CEX) test in an outpatient clinic.

METHODS

This is a quasi-experimental study with pre- and post-test comprising four groups in two terms of medical students' externship. The students' performance was assessed through the Mini-Clinical Evaluation Exercise (Mini-CEX) as a clinical performance evaluation tool. Structured written feedbacks were given to two experimental groups by designed feedback cards as well as verbal feedback, while in the two control groups feedback was delivered verbally as a routine approach in clinical education.

RESULTS

By consecutive sampling method, 62 externship students were enrolled in this study and seven students were excluded from the final analysis due to their absence for three days. According to the ANOVA analysis and Post Hoc Tukey test,  no statistically significant difference was observed among the four groups at the pre-test, whereas a statistically significant difference was observed between the experimental and control groups at the post-test  (F = 4.023, p =0.012). The effect size of the structured written feedbacks on clinical performance was 0.19.

CONCLUSION

Structured written feedback by cards could improve the performance of medical students in a statistical sense. Further studies must be conducted in other clinical courses with longer durations.

e-Consultation Improves Efficacy in Thoracic Surgery Outpatient Clinics

OBJECTIVE

The aim of this study is analysing the impact of the systematic versus occasional videoconferencing discussion of patients with two respiratory referral units along 6 years of time over the efficiency of the in-person outpatient clinics of a thoracic surgery service.

METHOD

Retrospective and comparative study of the evaluated patients through videoconferencing and in-person first visits during two equivalents periods of time: Group A (occasional discussion of cases) between 2008-2010 and Group B (weekly regular discussion) 2011-2013. Data were obtained from two prospective and electronic data bases. The number of cases discussed using e-consultation, in-person outpatient clinics evaluation and finally operated on under general anaesthesia in each period of time are presented. For efficiency criteria, the index: number of operated on cases/number of first visit outpatient clinic patients is created. Non-parametric Wilcoxon test is used for comparison.

RESULTS

The mean number of patients evaluated at the outpatient clinics/year on group A was 563 versus 464 on group B. The median number of cases discussed using videoconferencing/year was 42 for group A versus 136 for group B. The mean number of operated cases/first visit at the outpatient clinics was 0.7 versus 0.87 in group B (P=.04).

CONCLUSIONS

The systematic regular discussion of cases using videoconferencing has a positive impact on the efficacy of the outpatient clinics of a Thoracic Surgery Service measured in terms of operated cases/first outpatient clinics visit.