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PubMed1990

Issues in the evaluation of a community psychogeriatric service.

The need for evaluation of community psychogeriatric programs is stressed. The results of the evaluation of an outpatient service, with a liaison component, based in a community general hospital are presented. The use of treatment outcome scales, user satisfaction surveys, and a study of cost effectiveness are discussed. The issues of needs assessment, service models, staffing, target population, and the role of the family physician are addressed. It is recommended that evaluation processes be initiated by psychogeriatric services and that program data collection be developed in a manner that allows for service comparability, the assessment of ongoing community needs and the determining of program effectiveness.

Aged↗

PubMed2002

Measurement of outpatients' views of service quality in a Finnish university hospital.

AIMS OF THE STUDY: To describe the development of service quality in the surgical and medical outpatient departments of a university hospital. RATIONALE: Measurement and documentation of service quality and the use of these data as a basis for improvement are prerequisites for service improvement. METHODS: A survey conducted over a 3-week period using a 12-item questionnaire measuring service quality on a rating scale from 4 to 10 (extremely poor - excellent quality). Nineteen outpatient departments participated at a Finnish university hospital, 7679 voluntary patients visiting the outpatient departments between 1997 and 1999 completed the questionnaires. RESULTS: The questionnaire, which has not been described in use previously, proved to be a good tool enabling systematic access to patient feedback on service quality in outpatient departments. The instrument allowed the detection of strengths of the service provided by a large organization and long-term trends from patients' perspective. Patient evaluations were mainly good and the results improved year by year, although the instrument was built on questions concerning issues that were rated poorest by patients. The poorest ratings were related to access to information and adherence to appointment times. CONCLUSIONS: The service quality instrument offers a means to generate information to be used for service quality improvement in outpatient departments.

Adult↗

PubMed1992

Cigarette smoking, mortality, institutional and community-based care utilization in an adult community.

We evaluated mortality and health services utilization in a prospective study of 630 older residents of a Southern California community. All participants were 65 years or older when initially evaluated in 1973-1975. In addition to being followed for vital status each year, participants were reinterviewed in 1984-1986 and asked about nursing home, hospital, and community-based care for the interim period. Current cigarette use in 1973-1975 was a significant predictor of mortality for both men and women. In addition, former smoking status (before 1973-1975) significantly predicted both mortality and hospital inpatient utilization in men and women combined. However, smoking was not significantly associated with nursing home utilization or use of three categories of community-based care services. More research is necessary to identify the relationship between cigarette smoking and outpatient service use. The findings for mortality and inpatient hospital service utilization reaffirm the hazards of cigarette smoking.

Adult↗

PubMed1997

Health care costs of obesity in New Zealand.

OBJECTIVE: To estimate the costs of health care that are attributable to obesity in New Zealand. METHODS: The 1991 health care costs of non-insulin dependent diabetes, coronary heart disease, hypertension, gallstone disease, post-menopausal breast cancer and colon cancer were estimated and multiplied by the population attributable factor for obesity for each condition. The relative risk estimates were taken from the literature, the obesity prevalence from a 1990 New Zealand survey, and the costs and volumes of services were taken from a variety of sources and covered hospital (inpatient and outpatient) services, general practitioner consultations, pharmaceuticals, laboratory tests and ambulance services. Calculations were conservative and net of goods and services tax. RESULTS: A conservative estimate of the health care costs attributable to obesity for the six conditions was NZ$135 million. This represents about 2.5% of total health care costs which is similar to analyses from other countries. CONCLUSIONS: The health care costs of obesity as estimated are considerable. However, the total cost of overfatness to the New Zealand population is far greater than this because lesser degrees of overfatness, the health care costs of other obesity-related conditions such as arthritis, the costs to individuals of weight-loss programs and the indirect and intangible costs were not included in the analysis. A substantial and wide-ranging public health effort is needed to turn around the increasing prevalence and costs of obesity.

Adult↗

PubMedDate not supplied

The psychiatric nurse as outpatient psychotherapist.

Nursing therapy has predominantly reflected treatment within inpatient settings. There is little focus on outpatient services, where the psychiatric nurse can function as psychotherapist. Specific roles of one outpatient nurse therapist are outlined. Concrete guidelines in terms of supervision, support, and self-exploration are delineated for implementation by the nurse as outpatient psychotherapist.

Adolescent↗

PubMed1994

Developing an outpatient prospective payment system based on APGs for the Iowa Medicaid program.

This article describes the development of an outpatient prospective payment system (PPS) based on ambulatory patient groups (APGs) for the Iowa Medicaid Program. Currently, hospitals in Iowa are reimbursed for outpatient services on the basis of cost. Because of concern about escalating costs, the Iowa General Assembly mandated development of a hospital outpatient payment system to promote efficient use of resources and high quality care. The first use of APGs for payment across the full spectrum of services will be a testing ground that should have long term implications for outpatient prospective payment and quality improvement efforts.

Ambulatory Care↗

PubMed2005

[Clinical gastroenterology--luxury or standard of service in gastroenterology?].

Gastroenterology is one of the important specialities in internal medicine. The reform of the training curriculum for internal medicine and the reimbursement for inpatient and outpatient services in gastroenterology threatens the existence of internal medicine and gastroenterology in Germany, too. The capacity for training in internal medicine and gastroenterology is reduced by a decrease in the number of hospital beds in academic and community training centres. The concentration on gastrointestinal endoscopy in outpatient gastroenterology will be a result of an increasing demand for gastrointestinal endoscopy services and the decreasing number of gastroenterology clinics, respectively. Therefore, clinical gastroenterology as a core service in gastroenterology will be steadily eliminated. This development will diminish clinical gastroenterology to gastrointestinal endoscopy by eliminating the clinical services for chronic gastroenterological conditions such as, e.g., IBD, chronic hepatitis, reflux disease, IBS and functional dyspepsia. In this way gastroenterology looses its central role in health care services in specialised internal medicine. In 2003 the American Gastroenterological Association position paper: "Training the Gastroenterologist of the Future: the Gastroenterology Core Curriculum" was published. It has emphasised the role of clinical gastroenterology in medical training and medical services, too. Clinical gastroenterology consists of an array of several disciplines, e.g., GI physiology, GI research, infectious diseases, hepatology, oncology and gastrointestinal endoscopy, which all contribute to the effectiveness and efficiency in health care service. Financial incentives and better prospects of leading positions for young gastroenterologists in clinical gastroenterology have to be accomplished in order to nourish clinical gastroenterology in Germany. The German Association of Gastroenterology should negotiate with the responsible authorities for the addition of clinical gastroenterological services to the reimbursement by the EBM2000plus. The section of Gastroenterology of the German Association of Internists will provide sustained support to the achievement of this goal.

Delivery of Health Care↗

PubMed1996

Subcutaneous sumatriptan for the treatment of migraine: humanistic, economic, and clinical consequences.

OBJECTIVES: This study examined the humanistic, economic, and clinical consequences of using subcutaneous sumatriptan for 6 months for the acute treatment of migraine in 126 patients enrolled in a group-model health maintenance organization. METHODS: Patients received open-label sumatriptan (6 mg) for the treatment of migraines that occurred during a 6-month period. For each migraine, patients recorded migraine pain severity (none, mild, moderate, or severe) before treatment and 2 hours posttreatment and the time until onset of patient-defined meaningful relief. Patients also completed both the Short Form-36 Health Survey and Migraine-specific Quality of Life (QOL) Questionnaire at screening (to cover the period prior to initiation of treatment) and after 3 and 6 months of treatment. Patients' medical records were reviewed to obtain information on the frequency of migraine-related pharmacy use, general outpatient services, and urgent care services during the treatment period and the 12 months prior to initiation of treatment. RESULTS: By 2 hours after the dose, 71% of patients had moderate or severe pain reduced to mild or none, and 86% of patients achieved meaningful relief. At 3 months and 6 months, sumatriptan was associated with improvements relative to pre-sumatriptan baselines in Short Form-36 Health Survey and Migraine-specific QOL Questionnaire scores (P < .002). Sumatriptan was also associated with significant reductions in the average number of migraine-related general outpatient and urgent care services (P < .001). CONCLUSIONS: The use of sumatriptan for 6 months was associated with improvements in health-related quality of life, reductions in health care resource use, and a high percentage of treatment successes.

Adolescent↗

PubMed2006

Outpatient visit chaining among patients with serious mental illness.

BACKGROUND: To reduce travel burdens, patients may coordinate outpatient services to receive multiple encounters during a single day. Unmeasured visit "chaining" may bias estimates of the impact of accessibility barriers when utilization volume is measured using visit days. No studies have evaluated differential encounter chaining by distance. OBJECTIVES: We sought to evaluate the prevalence and predictors of visit chaining among patients with serious mental illnesses (SMIs), to evaluate whether patients living farther from providers are more likely to chain encounters, and to assess distance barriers using alternative measures of utilization volume. DATA SOURCES: We used the Veterans Affairs (VA) National Psychosis Registry, including Fiscal Year 2000 diagnosis and utilization data for 141,275 VA patients with SMI diagnoses. STUDY DESIGN: Random intercepts hierarchical regression to examine the relationship between distance to nearest VA provider and encounters/visit day, adjusting for age, gender, race/ethnicity, marital status, service-connection, previous hospitalization, and treatment setting and comorbidities at initial use. Negative binomial regressions to evaluate distance effects on visit day and encounter volume. Analyses adjusted for patient clustering within facilities. PRINCIPAL FINDINGS: With increased distance, patients had more encounters/visit day. Patients with bipolar disorder were more likely than patients with schizophrenia or other psychoses to chain treatments in association with greater distances. CONCLUSIONS: When utilization volume is measured in terms of visit days, analyses may overestimate distance barriers, because remote patients are more likely to chain encounters within visit days. However, distance remains a substantial barrier limiting total outpatient visit volume. Enhanced services coordination may reduce accessibility barriers for remote patients.

Adult↗

PubMed2005

The two-week waiting time standard for cancer: a neurosurgical perspective.

The implementation of the two-week wait initiative for cancer referrals in the NHS has had a major impact on outpatient services. A low clinical detection rate among GPs for neurological cancer has resulted in a large number of urgent referrals with a low yield of positive diagnoses. We have devised a strategy for minimizing the impact on outpatient clinics: patients are scanned prior to clinical review and those with normal scans are referred back to the GP without a clinic appointment. Out of 69 referrals of suspected CNS cancer made in 2003, 61 were scanned and six resulted in a positive diagnosis. The equivalent of 10 clinics was saved, and an increased speed of diagnosis and treatment was achieved with no compromise in patient care. Our study illustrates the consequences of the 2-week wait initiative on the neurosurgical service, and proposes an effective and safe solution.

Attitude of Health Personnel↗

PubMed2006

Understanding recent trends in Swiss ambulatory care utilization when out-of-pocket payment is minimal.

OBJECTIVE: To examine trends in ambulatory care utilization when individuals face almost no financial barriers to health care. METHODS: Observational study of insurance data. Adults with minimal deductible were included. Ambulatory care visits and costs were measured from 1997 to 2002. RESULTS: Mean ambulatory care costs/insuree increased from 1292.- to 1790.- CHF, corresponding to higher increases in drug costs (+61.7 %) than services costs (+24.3 %). The proportion of visits to generalists decreased while those to hospital outpatient services increased. CONCLUSIONS: In a demographically stable population of insurees, increases in ambulatory care costs were due neither to growth in physicians' visits nor to increasing physicians' fees per act, but to what was included in or prescribed during the visits.

Adult↗

PubMed1998

Differences between metropolitan and country public hospital allied health services.

This paper compares patient and episode characteristics in allied health services delivered in country and metropolitan hospitals. Eight public hospitals (46 allied health services) participated in the study (three country and five metropolitan sites, situated in South Australia, Queensland and Tasmania). Standardised rates of patient throughput were similar for country and metropolitan allied health services, despite smaller numbers of country staff providing services to larger geographical areas. Although the differences were not significant, country patients were generally older and had more chronic conditions than metropolitan patients. Fewer country patients than metropolitan patients were eligible for rebates in the private sector. In addition, fewer alternative services were available in country communities, which heightened the role of the public hospital outpatients services within the community. This paper provides an argument for similar funding arrangements for country and metropolitan ambulatory allied health services.

Adolescent↗

PubMed1992

[Community services and quality of life: a study of the impact in a remote region].

This longitudinal study with a matched comparison group was conducted in Abitibi, an area in North-West Quebec. Its goal was to observe the impact of community support services on the quality of life of long term psychiatric patients living in a remote area. A cohort of 47 subjects, living in a small town with a comprehensive network of community support services, was compared with a similar group living in a neighbouring city with only outpatient services. The satisfaction with life domains scale developed by Andrews and Withey and adapted by Baker and Intagliata was used at four times during the study. According to the results, the subjective perception of the quality of life in the two groups is comparable, even though the objective conditions are less favorable for the group participating in the community support program. The highest ratings were given to the place of residence, the neighborhood and its commodities; the lowest ratings were given to their love life and financial situation. One can observe a stability of the measures of quality of life over time and for the two groups. The perceptions of the sample living in a remote area are much more favorable than the ones of a comparable group living in the Montreal area. These results are discussed in a double perspective: the role of community support services in the daily life of people who are having severe and persistent problems of mental health, and the interest of measures of quality of life.

Adult↗

PubMedDate not supplied

[The geriatric university clinic].

The very old are the fastest growing population group. Medical progress allows more autonomy and better quality of life for the elderly. Traditional medical concepts are, however, only partly suited for dealing with age-associated problems. Medical education responds to these new requirements in a limited way. Interdisciplinary teamwork is a prerequisite in treating the multimorbid, acutely ill elderly patient. The task of the university is not only the development and implementation of high-tech medicine, but first of all a comprehensive training in medicine, including geriatrics. The Geriatric University Clinic therefore offers pre- and postgraduate training in geriatrics, but also in related disciplines by promoting teaching and research. In order to attain these goals, the geriatric acute ward was created for acutely ill, very old, multimorbid, frail elderly patients. A geriatric ward for rehabilitation complements this ward. A consultation service offers geriatric know-how to all other services. A special task is the early diagnosis and treatment of dementia in an outpatient service. The aim is to prevent chronification by early intervention and to reestablish satisfactory function and autonomy.

Aged↗

PubMed1990

From community mental health services to specialized psychiatry: the effects of a change in policy on patient accessibility and care utilization.

In 1975, a community mental health (CMH) centre with most of its resources channelled to outpatient services was set up in a defined catchment area of 75,000 inhabitants near Stockholm. In 1981, the CMH centre was allocated 3 inpatient wards of its own. An outpatient unit to treat long-term psychotic patients was also built up from existing resources. Emergency cases were directed to the primary health care services or to the emergency department of a hospital. During the same period, the number of doctors in the area's primary health care services increased fourfold. The social, demographic and diagnostic composition of the patient population and its utilization of in- and outpatient care in connection with these organizational changes are described. The population of the cathment area increased by 12.5% and the patient population decreased by 40%. The decrease was particularly great among first-time visitors (-54%), patients from lower social groups (-53%) and those with crisis diagnosis (-71%). The number of patients with psychoses increased (+26%). Outpatient visits and hospital utilization increased by one third. The number of compulsory admissions increased by 20% (still being far below the mean number in Stockholm). The decrease in the patient population is attributed to the reduction in accessibility to the CMH centre at a time when primary care services in the area were undergoing a sizeable expansion. The increased care utilization is the result of an internal redistribution of resources in favour of resource-demanding, long-term psychotic patients.

Adolescent↗

PubMed1979

[Theoretical and practical aspects of position and function of the outpatient department in the sectored psychiatric care system].

After discussion of the sectoring scheme, its advantages and the necessity for its realisation, important tasks of the sectored outpatient department are described. These include the mediating function of the OPD between local authorities and the whole psychiatric care system, concerns of early rehabilitation (Volovik) and psychotherapy, basic organisational and structural conditions of outpatient services, public relation activities, and continued training, co-operation with other authorities the necessary uniting of special outpatient department and psychiatric advisory centre.

Community Mental Health Services↗

PubMed1993

Health care utilization and costs after entry into an outreach program for homeless mentally ill veterans.

OBJECTIVE: This study evaluated the impact of a Department of Veterans Affairs outreach and residential treatment program for homeless mentally ill veterans on utilization and cost of health care services provided by the VA. METHODS: Veterans at nine program sites (N = 1,748) were assessed with a standard intake instrument. Services provided by the outreach program were documented in quarterly clinical reports and in residential treatment discharge summaries. Data on nonprogram VA health service utilization and health care costs were obtained from national VA data bases. Changes in use of services and cost of services from the year before initial contact with the program to the year after were analyzed by t test. Multivariate analyses were used to examine the relationship of these changes to indicators of clinical need and to participation in the outreach program. RESULTS: Although utilization of inpatient service did not increase after veterans' initial contact with the program, use of domiciliary and outpatient services increased substantially. Total annual costs to the VA also increased by 35 percent, from $6,414 to $8,699 per veteran per year. Both clinical need and participation in the program were associated with increased use of health services and increased cost. Veterans with concomitant psychiatric and substance abuse problems used fewer health care services than others. CONCLUSIONS: Specialized programs to improve the access of homeless mentally ill persons to health care services appear to be effective, but costly. Dually diagnosed persons seem especially difficult to engage in treatment.

Adult↗

PubMed1999

Treatment cost of acute exacerbations of chronic bronchitis.

In 1994, the National Center for Health Statistics estimated that more than 14 million people (54 per thousand) had chronic bronchitis and sought treatment for 90.9% of their acute episodes. However, few studies have been done on the treatment cost of chronic bronchitis using national data. We conducted a retrospective analysis of claims for patients treated for acute exacerbations of chronic bronchitis (AECB) to assess the frequency of services rendered and the costs to the health care system. Records were selected for the study based on a primary diagnosis of AECB according to the International Classification of Diseases, Ninth Revision, code. Medicare was the primary source of data on patients aged > or =65 years; data from the National Healthcare and Cost Utilization Project, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey were used for patients aged <65 years. We calculated a total treatment cost of $1.2 billion for patients aged > or =65 years and $419 million for patients aged <65 years. These calculations were based on the following: 280,839 hospital discharges resulting in hospital costs of $1.1 billion for the 207,540 patients aged > or =65 years, and $408 million for the 73,299 patients aged <65 years. The mean hospital length of stay was 6.3 days with a mean cost of $5497 for patients aged > or =65 years and 5.8 days with a mean cost of $5561 for younger patients. Room and board represented the largest percentage of the mean hospital costs of AECB. Inpatient physician services cost $32 million and $11 million for the 2 age groups, respectively. Diagnosis-specific data for outpatient services were found to be less reliable than inpatient data, possibly due to diagnostic coding omissions; 331,000 outpatient office visits for AECB were found for those aged > or =65 years and 237,000 visits for those aged <65 years, resulting in respective total outpatient costs of $24.9 million and $15.1 million. If the number of outpatient visits remain consistent with 1994 levels, there would be 5.8 million visits annually for those aged > or =65 years and 4.2 million visits for those aged <65 years; total outpatient costs would be $452 million and $317 million, respectively. Because the treatment costs of AECB are largely the costs of hospitalization, any new therapy that allows more patients to be treated in the outpatient setting is likely to generate significant savings.

Aged↗