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PubMed2005

Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002.

BACKGROUND: Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization. OBJECTIVE: The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV. DESIGN: Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002. SETTING: This study was conducted at 11 U.S. HIV primary and specialty care sites in different geographic regions. PATIENTS: In each year, HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002. MAIN OUTCOME MEASURES: Main outcome measures were number of hospital admissions, total days in hospital, and number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits. RESULTS: Mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. Mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be 514 dollars in 2000, 472 dollars in 2001, and 424 dollars in 2002; outpatient costs PPPM were estimated at 108 dollars in 2000, 100 dollars in 2001, and 101 dollars in 2002. CONCLUSION: Changes in utilization over this 3-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART.

AIDS-Related Opportunistic Infections↗
PubMed1988

An evaluation of Utah's primary care case management program for Medicaid recipients.

One of the first case management (CM) programs for limiting Medicaid enrollees' freedom of choice of provider was established by Utah. By assigning enrollees to specific providers responsible for arranging all nonemergency care, Utah intended both to improve access and to reduce program costs. State officials expected the program to increase recipients' use of primary-care providers, while reducing their use of specialists, prescription drugs, and hospital outpatient services. Savings from reductions in unnecessary use were expected to more than offset increases in outlays arising from access enhancements, resulting in lower program expenditures. This study investigated the extent to which the state Medicaid program achieved these goals. The analysis was based on a two-part multivariate model of usage, estimated from data created from claims-level information provided by Utah. The findings revealed that the use of primary-care physician services increased significantly. However, the program also raised the use of specialists' services and prescription drugs. In contrast, the use of hospital outpatient services was lowered. Overall, CM apparently achieved the objective of increased access, but failed to attain the cost-containment goal. The findings indicated that expected costs for ambulatory care rose by 25% in the early years as a result of case management.

Cost Control↗
PubMed1998

[Evaluation of extramural gerontopsychiatric treatment. I: On the possibility of clinical ambulatory and partial inpatient treatment of elderly psychiatric patients].

Based on data of a quantitative longitudinal study (one year) in two gerontopsychiatric catchment areas in Northrhine-Westfalia (FRG, City of Bielefeld and the district of Gütersloh) the question is discussed, whether an extramural (i.e. home-based outpatient- and day hospital-) treatment concept can be realized without selection of patients by diagnoses or severity of their mental disorders and that of their need of care. These three variables, which are important indicators of the necessary quality and quantity of treatment as well as of care for the patients, are surveyed. In three analytic steps the distribution of the gerontopsychiatric research population--concerning these three variables--over the three treatment settings (in-/outpatient and day hospital) in the two catchment areas is compared. For the district of Gütersloh--with an institution specialized on extramural treatment (the Gerontopsychiatric Center with a combination of a clinical outpatient service and a day hospital) the findings proof, that outpatient--in comparison with inpatient treatment--does not select patients by diagnoses nor by severity of their mental disorders nor by severity of their need of care. The outpatient service in Gütersloh--and nearly in the same degree the day hospital there--can actually integrate older patients with a higher severity of psychiatric symptoms and need of care in average than the inpatient departments in the two clinical gerontopsychiatric units under research.

Aged↗
PubMed2004

A double-blind randomised controlled trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain.

OBJECTIVE: To determine the effectiveness of laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain in women with endometriosis and women with no laparoscopic evidence of endometriosis. DESIGN: A prospective double-blind randomised controlled trial (RCT). SETTING: Single-centre, secondary-level gynaecology outpatient service and tertiary-level pelvic pain and endometriosis outpatient service in Auckland, New Zealand. POPULATION: One hundred and twenty-three women undergoing laparoscopy for investigation and management of chronic pelvic pain, 56 with no laparoscopic evidence of endometriosis and 67 with endometriosis. METHODS: Women were randomised from the two populations, firstly those with no evidence of endometriosis and secondly those undergoing laparoscopic surgical treatment for endometriosis, to receive LUNA or no LUNA. Participant and assessor blinding was employed. Follow up for pain outcomes was undertaken at 24 hours, 3 months and 12 months. MAIN OUTCOME MEASURES: Changes in non-menstrual pelvic pain, dysmenorrhoea, deep dyspareunia and dyschezia were assessed primarily by whether there was a decrease in visual analogue score for these types of pain of 50% or more from baseline and additionally whether there was a significantly different change in median visual analogue score. The numbers requiring further surgery or starting a new medical treatment for pelvic pain and complications were also measured. RESULTS: There was a significant reduction in dysmenorrhoea at 12 month follow up in women with chronic pelvic pain in the absence of endometriosis who underwent LUNA (median change in visual analogue scale (VAS) from baseline -4.8 versus-0.8 (P= 0.039), 42.1%versus 14.3% experiencing a successful treatment defined as a 50% or greater reduction in visual analogue pain scale for dysmenorrhoea (P= 0.045). There was no significant difference in non-menstrual pelvic pain, deep dyspareunia or dyschezia in women with no endometriosis undergoing LUNA versus no LUNA. The addition of LUNA to laparoscopic surgical treatment of endometriosis was not associated with a significant difference in any pain outcomes. CONCLUSIONS: LUNA is effective for dysmenorrhoea in the absence of endometriosis, although there is no evidence of effectiveness of LUNA for non-dysmenorrhoeic chronic pelvic pain or for any type of chronic pelvic pain related to endometriosis.

Adolescent↗
PubMed2001

A brief scale for assessing patients' satisfaction with care in outpatient psychiatric services.

OBJECTIVE: The authors evaluated the reliability and preliminary validity of the Charleston Psychiatric Outpatient Satisfaction Scale, a 15-item measure of patients' satisfaction designed for use in outpatient settings. The instrument uses a 5-point Likert-type response format that minimizes positive response bias and optimizes variability and predictive validity. METHODS: The Charleston Psychiatric Outpatient Satisfaction Scale was administered to 282 patients seen in psychiatric outpatient clinics affiliated with a public-academic psychiatric institution over a one-week period in 1995. RESULTS: The internal reliability of the instrument was high (alpha=.87), and its convergent validity was supported by the significant correlation of all items with anchor items that measured overall satisfaction with care and likelihood of recommending the clinic to others. The best predictors of overall ratings of care were the items measuring patients' satisfaction with helpfulness of the services and with the respect shown for patients' opinions about treatment. The best predictors of recommendation of the program to others were the items measuring satisfaction with matching of the treatment plan to patients' individual needs and with the respect shown for patients' opinions about treatment. Mean scores for all items ranged from 3.6 (satisfaction with parking) to 4.5 (satisfaction with helpfulness of the secretary and with the overall quality of care), indicating that overall satisfaction in this sample was high. CONCLUSIONS: The results provide preliminary support for the reliability and validity of the Charleston Psychiatric Outpatient Satisfaction Scale:

Adult↗
PubMed2000

[Comparison of the responsibility spectrum of a community psychiatric emergency service and outpatient emergency care in a psychiatric clinic].

PURPOSE: The need for psychiatric crisis services is generally accepted. Additional to traditional crisis clinics which are located in general or psychiatric hospitals in recent years also special community crisis services were implemented. The question is whether there are differences in patients and type of care between traditional and new services. METHODS: In this study empirical data are reported on reasons for contact, on patients and on interventions for a hospital based crisis clinic and a community crisis service. 132 service and 364 clinic contacts were recorded. RESULTS: There were more neurotic patients in the community service and more psychotic patients in the clinic. In both services inpatient care had to be arranged in one third of the cases. In the hospital based crisis service fewer legal commitments were necessary. A speciality of the community crisis service is the possibility to look after patients in their homes. CONCLUSION: Both services have similar features, but there are also differences which show that the new service offers new possibilities of care.

Ambulatory Care↗
PubMed1990

Utilization of outpatient health services by Army retirees and spouses.

To determine the sources and volumes of outpatient care used by one group of military beneficiaries, a data collection tool entitled the Outpatient Health Care Survey was developed and mailed to 496 Army retirees in southern Texas. This article details the results of that survey based on responses from 262 Army retirees and spouses.

Adult↗
PubMed2007

Swept away: use of general medical and mental health services among veterans displaced by Hurricane Katrina.

OBJECTIVE: This study examined national patterns of outpatient service use by veterans from regions affected by Hurricane Katrina. METHODS: Analyses tracked use of general medical and mental/substance use services in September and October through December 2005 in New Orleans and Biloxi-Gulfport compared to a cohort receiving care during the same months in the previous 2 years. RESULTS: In adjusted models, veterans from New Orleans and Biloxi-Gulfport were, respectively, 73% and 41% less likely in September 2005 to use any outpatient services as were cohorts from 2003-2004. Particularly in New Orleans, the relative decline in service use was substantially greater for specialty mental health and substance use services than for general medical services. CONCLUSIONS: Although many veterans were able to obtain care after Hurricane Katrina, there was a substantial disruption in delivery of Veterans Administration services, with disproportionate declines in mental health and substance use care.

Ambulatory Care Facilities↗
PubMed2002

Resource implications of a knee referral.

INTRODUCTION: The latest government targets state that by the end of 2005 the maximum waiting time for an outpatient appointment will be 3 months. These recommendations will not only increase the size of the outpatient clinics, but also the resources required thereafter. The purpose of this study was to analyse the outcome of new patient referrals to one knee outpatient service in order to quantify the resources required to investigate and treat these patients. METHOD: All new patients attending one consultant's knee outpatient service in the time period January 1st 1997 to December 31st 1997 were prospectively entered into a database recording patient details, source of referral and diagnosis. Eighteen months after the time period a cohort of 200 patients was randomly selected and the case notes were analysed. The number of outpatient appointment episodes, MRI scans, physiotherapy referrals and surgical episodes generated were recorded for each patient. RESULTS: Analysis of the initial database records show that a total of 662 new knee referrals were seen in 1997. Fifty-two percent (341) were made up of the five most common diagnoses, these being osteoarthritis, anterior knee pain, anterior cruciate ligament injury, medial ligament injury and medial meniscus injury. Retrospective analysis of the 200 patient notes revealed that these patients required a total of 499 outpatient episodes, 43 MRI scans, 180 courses of physiotherapy and 93 surgical episodes (53 elective and 40 emergency). These figures can be used to predict the resources that would be required by all new patients seen in an outpatient knee service in a year. DISCUSSION: Each new patient that enters the cycle of investigation followed by treatment must be met by extra resources. If this does not occur the net result will be that although government targets may be met, the time taken to complete each patient episode will become longer. It is imperative that before an agreement is made to see new patients the resources required to manage them are in place.

Ambulatory Care↗
PubMedDate not supplied

Setting up a deep vein thrombosis clinic.

The author describes the establishment of an outpatient service for patients with a suspected deep vein thrombosis. The outpatient service is on a medical admission unit at Glenfield Hospital, one of three sites of the University Hospitals of Leicester. The author considers that the service has been as effective as the inpatient service previously provided and in its first year of operation, 400 potential bed days were saved on positive to DVT patients.

Bed Occupancy↗
PubMedDate not supplied

Comprehensive mental health services: who needs them?

In 1980 the agency "Psychosocial Services" was founded in Vienna, Austria to set up and to operate comprehensive outpatient services, with responsibility to the total population of the city of 1.53 millions. Vienna has been divided into eight catchment areas. 11.076 patients have been in contact with the eight outpatient departments until the end of 1984 (0.72% of the total population). Data show high numbers of alcoholic, neurotic and schizophrenic patients. Number of patients indicates a need of some minimum equipment of the city with regionalized outpatient services. 50% of all the patients have never been under inpatient precare when they contact the outpatient departments.

Adult↗
PubMed1971

Value of re-examining x-ray films of outpatients attending accident services.

X-ray films of 4,665 patients who had attended an accident service as outpatients were reviewed by the clinicians and reported on by the radiologist the next day.In 20 cases the radiologist did not comment on bony injuries which had been diagnosed and treated by the accident service senior house officer. The radiologist, however, detected bony injuries which had been missed by the accident service senior house officer in 26 cases. In 10 cases injuries which had not been detected at the original examination or by the radiologist were noted when the x-ray films were reviewed. On two occasions the fracture was missed at all three examinations.The daily joint review of x-ray films by accident service officers and the radiologist seemed to increase the clinical and radiological acumen of the staff of the accident service.

Accidents↗
PubMed1986

[Initial experiences with the development of a psychiatric consultation service in relation to "psychiatry in crises situations"].

The integration of psychiatrists in a general hospital leads to the expectation that psychiatric and psychosocial crisis situations are encountered in a different way than the traditional hospitalization in a psychiatric clinic. The presented evaluation shows in which proportion of referred patients a crisis intervention took place. Without beds assigned as such for psychiatry patients there were more crisis interventions handled within the structures of the somatic wards than in the psychiatric outpatient service alone. The necessity of hospitalisation in a psychiatric clinic was discussed in 40% of all the cases of both the consultation-liaison service and the outpatient service of the social psychiatry team. Due to crisis intervention hospitalization in a psychiatric clinic was avoided for approximately 100 patients a year.

Commitment of Persons with Psychiatric Disorders↗
PubMed2000

TRICARE: Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); nonavailability statement requirement for maternity care. Office of the Secretary, DoD. Final Rule.

This final rule implements Section 712(c) of the National Defense Authorization Act for Fiscal Year 2000 (Pub. L. No. 106-65), which requires that a nonavailability-of-health-care statement shall be required for a beneficiary not enrolled in TRICARE Prime for TRICARE cost-share of maternity care services related to outpatient prenatal, outpatient or inpatient delivery, and outpatient post-partum care subsequent to the visit which confirms the pregnancy. The Act reestablishes a requirement which was previously eliminated under the broad direction of the National Defense Authorization Act for FY 1997, section 734, which removed authority for nonavailability statements (NASs) for outpatient services. Therefore, the Act changes the provisions which require an NAS for inpatient delivery, but do not require an NAS for outpatient prenatal and post-partum care. The change will significantly contribute to continuity of care for maternity patients. In furtherance of that principle, and consistent with the previous policy, an NAS for maternity care shall not be required when a beneficiary has other health insurance for primary coverage.

Female↗
PubMed1992

Patterns of utilization of outpatient mental health services by children and adolescents.

Although as many as one-fifth of children and adolescents may meet DSM-III criteria for at least one psychiatric diagnosis, data from the Minnesota Department of Human Services for 1988 show that only 20 to 38 percent of children and adolescents in the state who are eligible for medical assistance and who are potentially in need of psychiatric care are referred for or seek treatment. A study of publicly funded mental health care for youths under 18 found that in 1988 the average cost for state-supported psychiatric services per outpatient case was $520, compared with $8,556 per inpatient case. However, overall cost of state-supported mental health services for youths under 18 increased by 28 percent between 1987 and 1988, primarily due to increases in payments for inpatient care of patients with dual diagnoses of mental illness and chemical dependency.

Adolescent↗
PubMed2003

Patients with and without intellectual disability seeking outpatient psychiatric services: diagnoses and prescribing pattern.

BACKGROUND: The present study examined the presenting problem of psychiatric outpatients, and resulting diagnostic and prescribing patterns, comparing patients with intellectual disability (ID) with non-ID (N-ID) patients seen in the same clinic. METHODS: This study was a retrospective medical chart review of information in the first psychiatric diagnostic evaluation for the most recent 100 adult patients with mild ID, 100 patients with moderate, severe or profound ID, and 100 matching N-ID patients. RESULTS: There were significant differences in rates of medical illness, disabilities, history of marriage, children, independent living, and family history of psychiatric and neurological disorders. Individuals with ID were more likely to present with aggression, self-injurious behaviour or physical complaints, whereas N-ID subjects presented more frequently with depression and anxiety complaints. For all groups, depressive disorders were the most frequent class of diagnoses. For those with ID, antipsychotics were used in 32% of subjects, with mood stabilizers in 28% and antidepressants in 27%. The N-ID subjects were most frequently prescribed antidepressants (40%) and anxiolytics (22%). Polypharmacy did not differ significantly among groups. CONCLUSIONS: Psychiatric practitioners relied on the diagnostic examination to formulate their diagnosis, whereas the chief complaint reflected the view of caregivers of the subjects with ID. In contrast to previous studies, outpatient providers frequently diagnosed depression, and the prescribing pattern showed increased usage of antidepressants and mood stabilizers.

Ambulatory Care↗