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PubMed2002

Review of the function of a telephone helpline in the treatment of outpatients with rheumatoid arthritis.

OBJECTIVES: To examine the role, acceptability, and cost effectiveness of a telephone helpline organised and run by specialist nurses in a district general hospital outpatient rheumatology department. MATERIAL AND METHODS: Patients accessed the telephone helpline by leaving a taped message on an answer phone with a 24 hour response time. Assessment included an audit of the nature and outcome of helpline calls, patient satisfaction with the helpline, and a health economic analysis of the helpline operation. A postal questionnaire was used to assess patient satisfaction; this was sent to the 87 patients who called the helpline during one month, and overall satisfaction with the helpline was assessed. The nature and outcome of all calls was analysed retrospectively using a helpline record book for February and October of one year and February of the following year. From the results of the retrospective analysis and an estimate of the number of general practitioner consultations avoided by provision of the helpline, the cost effectiveness of the helpline was calculated. RESULTS: Of those returning questionnaires, 61/63 (97%) were satisfied with the response time, 63/63 (100%) with the courtesy, and 60/63 (95%) felt that their questions were answered directly and to their satisfaction in 62 (98%) of cases. Had the helpline not been available, 38/63 (60%) patients would have made an appointment with their GP. When these figures were extrapolated to an annual estimation, a basic cost analysis showed that the helpline produced a cost saving to the NHS, largely as a result of GP consultations avoided. CONCLUSION: Clinical advice and support can be provided by a rheumatology helpline set up as an adjunct to a standard outpatient service. The results of a postal questionnaire suggested more than 95% satisfaction with all aspects of the helpline service and that 99% of callers would call the helpline again. The provision of the helpline service contributes to the quality of care provided by an outpatient department and provides benefit to the NHS.

Adolescent↗
PubMed2001

The public health impact of Alzheimer's disease, 2000-2050: potential implication of treatment advances.

Recent developments in basic research suggest that therapeutic breakthroughs may occur in Alzheimer's disease treatment over the coming decades. To model the potential magnitude and nature of the effect of these advances, historical data from congestive heart failure and Parkinson's disease were used. Projections indicate that therapies which delay disease onset will markedly reduce overall disease prevalence, whereas therapies to treat existing disease will alter the proportion of cases that are mild as opposed to moderate/severe. The public health impact of such changes would likely involve both the amount and type of health services needed. Particularly likely to arise are new forms of outpatient services, such as disease-specific clinics and centers. None of our models predicts less than a threefold rise in the total number of persons with Alzheimer's disease between 2000 and 2050. Therefore, Alzheimer's care is likely to remain a major public health problem during the coming decades.

Alzheimer Disease↗
PubMed2002

Current status of hospice cancer deaths both in-unit and at home (1995-2000), and prospects of home care services in Japan.

In Japan, the first government-approved hospice (GAH) and palliative care unit was established and commenced operations in 1990, and hospice medical care was made eligible for health insurance coverage. By 31 December 2000, the number of GAH institutions had increased to 86 (1,590 beds). The ratio of hospices to population in Japan is currently approximately 1:1.5 million, with an average of one hospice bed for approximately every 80,000 people. This study of institutions reports a survey conducted to determine the number of deaths (hospice unit and home) of GAH cancer patients, and to determine the servicing status of hospice home care for the period 1995 through 2000. The place of death of the patients cared for by GAHs in 2000 were: hospice units 97.7% and home 2.3%. GAH patient deaths (both inpatient and at home) in 2000 was 2.6% of the total number of cancer patients' deaths, an increase of 3.8-fold since 1995. Of the total number of GAH institutions, 62% are engaged in home care services and 91 % offer hospice care by hospice-assigned doctors. In addition, 72% offer team care with nurses based at Home Care Agencies. In order for the hospice (including home care service) to become established in a way most appropriate to each region of Japan, GAH institutions must assume significant promotional roles in their respective regions. One of the goals and assignments of establishing medical service with hospice home care in Japan is to develop the systematic care programs of GAH institutions, which include home care service in addition to the already established hospice unit and outpatient services.

Home Care Services↗
PubMed2004

Utilization of mental health services by low-income pregnant and postpartum women on medical assistance.

This paper examines mental health service use among publicly insured white and African-American pregnant and postpartum women who live in a metropolitan area. The study examines the extent to which ethnicity, physical health problems, and behavioral health risk factors are associated with the probability of service use during the prenatal-postpartum period. It also analyzes the patterns of service utilization for those women who used mental health services. Medicaid claims and eligibility data, County Reporting System claims and admissions data, and Pennsylvania State Vital Birth Records were integrated using a unique algorithm. Logistic regression was employed to estimate the probability of mental health service use among 3,841 low-income women residing in Philadelphia who were continuously enrolled in Medicaid for 9 months preceding delivery and 6 months postpartum. Analyses were also conducted on the intensity and location of service use, as well as psychiatric diagnosis, during pregnancy and the postpartum period. About 10% of the women used mental health services during the study period. Women were more likely to use services if they were Caucasian, had a number of chronic diseases, had a number of pregnancy complications, and smoked. Among users, the same proportion (ca. 6%) used services during pregnancy and postpartum, with the average number of outpatient visits slightly higher during pregnancy than during the postpartum period. Most outpatient services (86%) were delivered in the specialty sector. Most women who used mental health services (84%) were diagnosed with minor psychiatric disorders including minor depression and anxiety disorders. Women who used services during the postpartum only were more likely to be diagnosed with major depression, whereas women who used services throughout the perinatal period were more likely to be diagnosed with severe mental disorders. Health providers can use information generated in this study to identify women who are likely to have a need for mental health services.

Adolescent↗
PubMed1993

Growth in Medicare inpatient physician charges per admission, 1986-1989.

Recently, there has been increasing interest in alternative Volume Performance Standards centered around the hospital medical staff. Using a national sample of Medicare claims, this paper analyzes growth in Medicare inpatient physician charges per admission between 1986 and 1989, by specialty, type of service, and type of hospital. Although growing more slowly than outpatient services, inpatient physician service volume and intensity growth is substantial. Inpatient physician services grew at an annual rate of 8.3%-31% of which was attributable to prices, 27% to case mix, and 41% to volume and intensity. Services provided by cardiologists, gastroenterologists, and other medical specialists demonstrate annual volume and intensity increases exceeding 13% annually. Consultations, hospital visits, and specialist services account for a third of all services provided during the admission and also demonstrate rapid annual rates of growth.

Diagnosis-Related Groups↗
PubMed1991

Outpatient care programs of mental health organizations, United States, 1988.

In 1988, 2,989 (60 percent) of the 4,961 mental health organizations in the United States (including the territories) offered outpatient care programs. A total of 5.8 million patient care episodes were generated by these organized outpatient programs. These episodes included 3.1 million outpatient additions, produced 54 million outpatient visits, and represented 67 percent of all patient care episodes in mental health organizations in 1988. Although the number of mental health organizations with outpatient care programs increased by less than one percent between 1986 and 1988, the number of outpatient additions showed an 11 percent gain during this period. Multiservice mental health organizations were the primary locus of outpatient care in 1988, accounting for 41 percent of the 2,989 mental health organizations providing this care. Ranking next in this respect, were free-standing psychiatric outpatient clinics, and the separate psychiatric outpatient services in non-Federal general hospitals, with 25 and 16 percent, respectively, of the total outpatient care programs. In general, these three organization types had similar rankings with respect to the volume of the outpatient caseload. By definition, all of the freestanding psychiatric outpatient clinics provided outpatient care, and almost all of the VA mental health programs and multiservice mental health organizations also offered this care (99 and 92 percent, respectively). In contrast, psychiatric outpatient care was available in only 37 percent of non-Federal general hospitals with separate psychiatric services, 36 percent of private psychiatric hospitals, 29 percent of State mental hospitals, and 22 percent of RTCs for emotionally disturbed children. Outpatient care was available in mental health organizations in all States in 1988, with every State having at least two or more organization types providing this service. In general, the most populous States had the largest number and the greatest variety of mental health organizations with outpatient care programs. Of the 2.87 million clients receiving outpatient care in mental health organizations at the end of 1988, 23 percent were under 18 years of age, 68 percent were 18 to 64, and 9 percent were 65 and older. Male outpatient clients slightly outnumbered female clients. The majority (77 percent) of the outpatient clients were white, with blacks representing 21 percent; native Americans and Asians/Pacific Islanders, the remaining two percent. Eleven percent of the total client population were reported to be of Hispanic origin.(ABSTRACT TRUNCATED AT 400 WORDS)

Ambulatory Care↗
PubMed2001

Survival patterns among HIV+ individuals based on health care utilization.

The purpose of this study was to determine if HIV+ persons who first obtained health care in New Orleans through public hospital inpatient services had a higher risk of death or disease progression than patients who first entered care through public outpatient services. The sites included the largest HIV outpatient clinic in the Gulf South, two early intervention sites and a public hospital. A medical record review on patients who attended these sites from July 1995 through December 1999 and were enrolled in the Adult Spectrum of Disease (ASD) Study was conducted (n = 3402). The multivariate analysis examined the associations between inpatient services and the main effects. Kaplan-Meier analysis and Cox proportional hazards regression were performed. Risk of death or disease progression was analyzed for three different endpoints: time from study entry to death, time from HIV to AIDS, and time from AIDS to death. The multivariate analysis showed that patients first entering care through inpatient services were significantly more likely to be African American, have AIDS, and use drugs. The risk of death or disease progression was significantly higher for all three endpoints. Results from this study indicate that HIV+ individuals receiving initial care through public hospital inpatient services may require more effective early intervention.

Acquired Immunodeficiency Syndrome↗
PubMed1982

Medicare program; comprehensive outpatient rehabilitation facility services--Health Care Financing Administration. Final rule.

These regulations expand the scope of benefits under Medicare-Part B to include services furnished by comprehensive outpatient rehabilitation facilities (CORFs). They establish the conditions these facilities must meet to participate in Medicare, define CORF services, specify the conditions under which those services will be covered, and establish CORF reimbursement on a reasonable cost basis. The regulations are necessary to implement section 933 of the Omnibus Reconciliation Act of 1980 (Pub. L. 96-499). The purpose is to enable beneficiaries to receive coordinated comprehensive rehabilitation services at one location, rather than having to go to different sources.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1998

Satisfaction with outpatient health care services in Manica Province, Mozambique.

The objective of the study was to describe ambulatory health care services, determine the level of client satisfaction, and identify obstacles to care in a rural area of Mozambique. Exit surveys at 34 health clinics in Manica Province were completed on a sample of 879 adults representing between 1% and 2% of the average monthly visit totals at each clinic. Eighty-three per cent of interviewees were women. Just over half of the visits were for paediatric patients. Men were more likely to be at the clinic for their own health care needs than women (81% vs. 40%, p < 0.001). Of patients seen for acute illness, 45% were examined, 22% received preventive education, and 23% received prognostic information. Overall, 55% of interviewees believed that the service they received was good or very good, 32% rated it as fair, and 13% as poor. Satisfaction was positively associated with increased training level of the provider (p < 0.005), and shorter waiting times (p < 0.001). The most common complaints about the clinic visits were lack of adequate transportation, long waiting times, lack of physical examinations, and failure to receive prescribed medications. These findings suggest that the majority of Mozambicans interviewed are moderately satisfied with the available outpatient services in Manica. Provider training, provider availability and distribution of medicines were areas identified by respondents as needing improvement.

Adolescent↗
PubMed2000

Evaluating Child Health Plus in upstate New York: how much does providing health insurance to uninsured children increase health care costs?

BACKGROUND: In response to the increase in the number of American children without health insurance, new federal and state programs have been established to expand health insurance coverage for children. However, the presence of insurance reduces the price of care for families participating in these programs and stimulates the use of medical services, which leads to an increase in health care costs. In this article, we identified the additional expenditures associated with the provision of health insurance to previously uninsured children. METHODS: We estimated the expenditures on additional services using data from a study of children living in the Rochester, New York, area who were enrolled in the New York State Child Health Plus (CHPlus) program. CHPlus was designed specifically for low-income children without health insurance who were not eligible for Medicaid. The study sample consisted of 1910 children under the age of 6 who were initially enrolled in CHPlus between November 1, 1991 and August 1, 1993 and who had been enrolled for at least 9 continuous months. We used medical chart reviews to determine the level of primary care utilization, parent interviews for demographic information, as well as specialty care utilization, and we used claims data submitted to CHPlus for the year after enrollment to calculate health care expenditures. Using this information, we estimated a multivariate regression model to compute the average change in expenditures associated with a unit of utilization for a cross-section of service types while controlling for other factors that independently influenced total outpatient expenditures. RESULTS: Expenditures for outpatient services were closely related to primary care utilization-more utilization tended to increase expenditures. Age and the presence of a chronic condition both affected expenditures. Children with chronic conditions and infants tended to have more visits, but these visits were, on average, less expensive. Applying the average change in expenditures to the change in utilization that resulted from the presence of insurance, we estimated that the total increase in expenditures associated with CHPlus was $71.85 per child in the year after enrollment, or a 23% increase in expenditures. The cost increase was almost entirely associated with the provision of primary care. Almost three-quarters of the increase in outpatient expenditures was associated with increased acute and well-child care visits. CONCLUSIONS: CHPlus was associated with a modest increase in expenditures, mostly from additional outpatient utilization. Because the additional primary care provided to young children often has substantial long-term benefits, the relatively modest expenditure increases associated with the provision of insurance may be viewed as an investment in the future.

Child↗
PubMed1987

Use of outpatient mental health services over time in a health maintenance organization and fee-for-service plans.

The authors compared the use of outpatient mental health services in a health maintenance organization (HMO) and fee-for-service plans over a 5-year period, using data from a randomized controlled trial. In any given year, enrollees in the HMO and a fee-for-service plan with identical benefits were equally likely to visit a mental health specialist. Over several years, the HMO enrollees were about 50% more likely ever to visit a mental health specialist; fee-for-service enrollees were more likely to receive mental health care in more than 1 study year.

Adult↗
PubMed1996

Psychiatric CNS consultation model in a medical setting.

A model for psychiatric CNS consultation services offered in a comprehensive cancer center is presented. The model combines inpatient and outpatient services; these services, described separately, are compared with and contrasted to those reported in the literature. Although many models of inpatient psychiatric CNS consultation-liaison activities have been published, the literature offers few descriptions of the psychiatric CNS in either independent or collaborative outpatient practice. CNSs, therefore, need to inform colleagues and consumers about the nature of their advanced practices. In the model described, the psychiatric CNSs receive direct referrals for both hospital and clinic patients as well as patients receiving cancer treatment outside the cancer center. CNSs evaluate patients independently, requesting medical psychiatric assessment and intervention when necessary. The independence with which the psychiatric CNSs function provides many patients with access to psychiatric services. The flexibility to follow patients in both in- and outpatient settings also offers continuity of care.

Adult↗
PubMed1997

Causes and costs of spinal cord injury in the United States.

A cross-sectional multicenter study was conducted to estimate the direct costs for each cause of spinal cord injury in the United States. Random samples of 227 new injuries and 508 persons 2-16 years postinjury were selected. Prospective data were collected during one year on all charges for emergency medical services, hospitalizations, attendant care, equipment, supplies, medications, environmental modifications, physician and outpatient services, nursing homes, household assistance, vocational rehabilitation, and miscellaneous items. In 1995 dollars, first year charges averaged $233,947 for vehicle crashes, $217,868 for violence, $295,643 for sports, $185,019 for falls and $208,762 for other causes. Recurring annual charges for each cause averaged $33,439, $17,275, $27,488, $26,238 and $23,510, respectively. Using average age at time of injury for each cause, a 2% real discount rate, and the most recent survival data from the National Spinal Cord Injury Statistical Center, average lifetime charges for each cause were $969,659, $613,345, $950,973, $630,453 and $673,749, respectively. Given an estimated 10,000 new cases of spinal cord injury occurring each year of which 35.9% are caused by vehicle crashes, 29.5% are caused by violence, 20.3% are caused by falls, 7.3% are caused by sports, and 7% result from other causes, annual aggregate direct costs of traumatic spinal cord injury in the United States are $3.48 billion for vehicle crashes, $1.81 billion for violence, $1.28 billion for falls, $694 million for sports and $472 million for other causes. Total direct costs for all causes of SCI in the United States are $7.736 billion.

Accidental Falls↗
PubMed1991

Hand function in patients with diabetes mellitus.

Using validated clinical tests and standardized controls, we measured hand function in diabetic subjects. Fifteen diabetic patients (median age 48 years), all having used insulin for a minimum of 5 years, were randomly selected from inpatient and outpatient services of an academic medical center. Testing was done on an outpatient basis. The three hand function tests used were the Purdue Pegboard, O'Connor Tweezer Dexterity, and Smith Hand Function. A symptom questionnaire was also included in the study. Function was significantly decreased in the diabetic group, and the decrease was out of proportion to their own subjective pretest assessments. These findings may have implications for occupational performance as well as activities of daily living.

Activities of Daily Living↗
PubMed2003

Symptoms in 400 patients referred to palliative care services: prevalence and patterns.

The demographics and prevalence of symptoms in patients at first referral to the different components of palliative care services were identified by a retrospective case note study of 400 patients referred to three palliative care centres in London, UK: Michael Sobell House, Mount Vernon Hospital; The North London Hospice; St Bartholomew's and the Royal London Hospitals. One hundred consecutive referrals to each of the following service components were analysed: a hospice inpatient service; a community team; an NHS hospital support team and an outpatient service. A standardized proforma was used to collect the data. Ninety five per cent (380/400) of patients referred had a cancer diagnosis. The five most prevalent symptoms overall were pain (64%), anorexia (34%), constipation (32%), weakness (32%) and dyspnoea (31%), which is similar to other published reports. However, the commonest symptoms and their prevalence varied depending on the service component to which the patient was referred. Patients referred to hospice and community services had the highest symptom burden (mean number of symptoms per patient 7.21 and 7.13, respectively). This study suggests that different patient subgroups may have different needs in terms of symptoms, which will be relevant for the planning and rationalization of palliative care services.

Adolescent↗
PubMed1997

Illegal drug use among rural adults: mental health consequences and treatment utilization.

This study uses the National Household Survey on Drug Abuse to examine mental health consequences and treatment utilization among nonmetropolitan and rural adults. The study employs an ecological system perspective, dividing the study population into three groups: nonmetropolitan-rural, nonmetropolitan-urban, and metropolitan-rural. Logistic regression analysis is used to examine four sets of factors related to self-report of mental health problems among drug-using adults, including community level features, family characteristics, personal characteristics, and stress factors. Perceived ease of purchasing cocaine, number of moves in last five years, employment in blue-collar occupations, number of jobs in last five years, and residence in neighborhoods with a low rate (< 10%) of minority households were significantly related to self-report problems. Results of the analysis are discussed in terms of barriers to utilization of treatment and rehabilitation services among nonmetropolitan and rural adults, such as availability and access to facilities and professional services, social stigma, ability to afford services, and the difficulty for rural communities to support inhospital and outpatient services.

Adult↗
PubMed1993

The effect of smoking on health service utilization.

This study involved direct observation of the differences in prevalence of disease and utilization of medical care by smokers, non-smokers, and ex-smokers. The data was collected from the 1989 Korean National Health Survey (1989 KNHS). A total of 5,201 individuals ages 20 to 59 were randomly selected from the whole Korean population using the three-stage stratified random sampling. Based on the logistic regression, the following results were obtained. Compared with the non-smokers, the relative risks for an acute disease were 1.9 and 1.7 for male ex-smokers and female current smokers, respectively. Smoking behavior significantly increased utilization of health services such as admissions (RR = 2.5 for current smokers) among females, outpatient visits (RR = 2.1 for ex-smokers, RR = 2.3 for age began to smoke was less than 18 years) among males and (RR = 1.5 for current smokers) among females. Furthermore, the utilization of outpatient services for ex-smokers who were self-concerned about their health was 3.4 times higher than the non-smokers. Based on the weighted least square regression model the days of medication for male current smokers and ex-smokers were significantly longer than non-smokers. These effects persisted after controlling for major identified confounding factors. Thus, the results of this study confirmed that smoking is an important cause of diseases and a major contributing factor to the use of health services.

Adult↗
PubMedDate not supplied

Shift work for specialist registrars in acute medicine: more questions than solutions.

Trainees' hours are under review once again, due to the changes incurred by the latest pay deal and the likely enforcement of the European Working Time Directive. Until now, specialist registrars (SpRs) training in general internal medicine (GIM) have been accustomed to residential on-call rotas or partial shift schemes as a means of covering emergency work. Some NHS trusts have suggested that GIM SpRs should now work full shifts to meet the restrictions of European Working Time Directive. This article outlines the views of the Royal College of Physicians' Trainees Committee on the potential impact of full shift work for GIM SpRs on medical services. Impaired continuity of inpatient care and reduced staffing levels for outpatient services were felt to be the most serious possible consequences. Some short-term solutions are suggested, but in the long term, increased numbers of both consultants and SpRs will be vital to maintain and improve standards in acute medicine.

Consultants↗