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PubMed2003

An audit of a specialist registrar-run outpatient diagnostic hysteroscopy service in a district general hospital.

We aimed to audit a specialist registrar-run outpatient hysteroscopy service. This was a retrospective audit conducted in small district general hospital. All patients attending the outpatient hysteroscopy clinic during a 3-month period were studied. The patients' medical notes were used to collect data. Forty-five women attended the outpatient hysteroscopy clinic during the 3-month time period. The hysteroscopy was performed satisfactorily in 91.1% of cases. Pathology was found in 39% of cases. In 34.1% of cases an endometrial polyp was found and in 7.3% of cases a submucous fibroid was seen. An endometrial biopsy was performed in 65.8% of cases and no malignancies were found. The inpatient hysteroscopy rate was higher than expected due to the high incidence of polyps, not because women could not be satisfactorily hysteroscoped in the clinic. A registrar-run outpatient hysteroscopy clinic is a viable and useful tool. Audit standards can be set and protocols developed.

Adult↗
PubMed2001

Managing up to maximize medicare reimbursement for outpatient care.

An example of managing up through participation in a multidisciplinary team tasked with maximizing reimbursement under the Medicare ambulatory patient classification (APC) system is described. Medicare's new system of payment for hospital outpatient services replaces the cost-based reimbursement model of the past with a technical payment based on the outpatient evaluation and management level. Individual institutions are responsible for developing criteria for defining technical visit levels. Managers at the New England Medical Center formed a team to develop these criteria. The team outlined components of the patient visit that qualified as technical costs, such as the use of space at a facility, medical and surgical supplies, and nonphysician professional services. Team members then contacted each of the center's clinics to identify specific services that met these criteria. After formulating the technical visit level criteria, the team determined who would assign the technical visit level, wrote policies and procedures, and trained staff. The APC team also assessed billing procedures, focusing particularly on the accuracy of the charge master and the use of proper codes and billing units for pass-through drugs. The team continues to monitor its results by reviewing payments received from Medicare and auditing high-risk areas. The APC team used the principles of managing up to maximize Medicare reimbursement for outpatient visits.

Ambulatory Care↗
PubMed2005

Use of leverage to improve adherence to psychiatric treatment in the community.

OBJECTIVES: A variety of tools are being used as leverage to improve adherence to psychiatric treatment in the community. This study is the first to obtain data on the frequency with which these tools are used in the public mental health system. Patients' lifetime experience of four specific forms of leverage-money (representative payee or money handler), housing, criminal justice, and outpatient commitment-was assessed. Logistic regression was used to examine associations between clinical and demographic characteristics and receipt of different types of leverage. METHODS: Ninety-minute interviews were conducted with approximately 200 adult outpatients at each of five sites in five states in different regions of the United States. RESULTS: The percentage of patients who experienced at least one form of leverage varied from 44 to 59 percent across sites. A fairly consistent picture emerged in which leverage was used significantly more frequently for younger patients and those with more severe, disabling, and longer lasting psychopathology; a pattern of multiple hospital readmissions; and intensive outpatient service use. Use of money as leverage ranged from 7 to 19 percent of patients; outpatient commitment, 12 to 20 percent; criminal sanction, 15 to 30 percent; and housing, 23 to 40 percent. CONCLUSIONS: Debates on current policy emphasize only one form of leverage, outpatient commitment, which is much too narrow a focus. Attempts to leverage treatment adherence are ubiquitous in serving traditional public-sector patients. Research on the outcomes associated with the use of leverage is critical to understanding the effectiveness of the psychiatric treatment system.

Adult↗
PubMed2003

Medicare program, changes to the hospital outpatient prospective payment system and calendar year 2004 payment rates. Final rule with comment period.

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In addition, it describes changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2004. Finally, this rule responds to public comments received on the August 12, 2003 proposed rule for revisions to the hospital outpatient prospective payment system and payment rates (68 FR 47966).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

National estimates of mental health utilization and expenditures for children in 1998.

No recent national data on expenditures and utilization are available to provide a benchmark for reform of mental health systems for children and adolescents. The most recent estimates, from 1986, predate the dramatic growth of managed care. This study provides updated national estimates. Treatment expenditures are estimated to be $11.68 billion ($172 per child). Adolescents have the highest expenditures at $293 per child followed by $163 per child aged 6 to 11 and $35 per preschool-aged child. Outpatient services account for 57%, inpatient for 33%, and psychotropic medications for 9% of the total. Unlike earlier reports, outpatient care now accounts for the majority of expenditures. This finding replicates the differences between recent managed care data and earlier actuarial databases for privately insured adults and confirms the trend from inpatient toward outpatient care.

Adolescent↗
PubMed1988

Language disorders and attention deficit disorders in young children referred for psychiatric services: analysis of prevalence and a conceptual synthesis.

Nearly two-thirds of a group of preschool children referred for psychiatric outpatient services were found to have language disorders when assessed by standardized procedures, a higher number than reported in previous studies. Significant interrelationships between language disorders and attention deficit disorders were found. Analyses of prevalence rates, gender ratios, and selected psychosocial factors led to reformulation of approaches to assessment and treatment of young children with severe psychiatric problems.

Attention Deficit Disorder with Hyperactivity↗
PubMed1981

A comparison of mental health costs and utilization under three insurance models.

Published reports on utilization and costs of mental health services provided under three insurance models (prepaid, cost-financed and indemnity) reveal consistently greater utilization of outpatient services, lower overall inpatient utilization and comparable costs among prepaid plans in contrast with other two models. The present study suggests that prepaid plans, by facilitating the use of specialty mental health services by a substantially greater proportion of their membership than the other two models, come closer to serving their total population in need as projected by epidemiologic studies. While the data on cost containment are less clear, prepaid plans show a shift in costs away from inpatient and toward outpatient care. However, because of the possibility of bias of differences in population served, treatment philosophy and benefits offered, conclusions drawn from these findings must be tentative until a prospective comparison controlling for these differences can be carried out.

Costs and Cost Analysis↗
PubMed2004

Predictors of outpatient mental health service use--the role of foster care placement change.

This study examined the relationship between placement change and outpatient mental health service use. It is based on (1) conceptual propositions about the impact of the foster care living context on mental health service use, and (2) empirical knowledge about the adverse consequences of placement change. Results of the study, which were based on a cohort of 570 children in foster care in San Diego County, suggest an association between placement changes in child welfare and use of outpatient mental health services. Specifically, an increase in the number of placement changes predicted a greater rate of outpatient mental health visits. The study further found that children who experienced behavior-related placement changes received more outpatient mental health visits than children who experienced placement changes for other reasons. Follow-up analyses of the 144 children who experienced any behavior-related placement changes further indicated that the rate of outpatient mental health service use almost doubled in the 90 days following the first behavior-related placement change. Findings from this study have implications for the practice, policy and research fields in child welfare as well as mental health.

Adolescent↗
PubMed2004

Use of mental health services by youths in public sectors of care.

The present paper examined the lifetime rates of mental health service use in a representative sample of youths identified as receiving services in at least one sector of care in a publicly funded service system of a large, metropolitan area. Service use was examined in relation to age, gender, mental health diagnostic status, and service sector involvement. Participants were 1706 youths ages 6-17 years who were active in at least one of the following service sectors: alcohol and drug services, child welfare, juvenile justice, mental health, and special education services for serious emotional disturbance. Structured service use and diagnostic interviews were administered to youths and their caregivers. High lifetime rates of mental health service use were found. Eighty-seven percent of the sample used at least one outpatient service, 45% used at least one inpatient service, and 71% reported use of a school-based service. Youths involved with the mental health and special education sectors had the highest rates of service use. In contrast, youths enumerated from the juvenile justice system tended to have the lowest rates of use. Additional research is needed to refine our understanding of the factors associated with the observed patterns of service use.

Adolescent↗
PubMed2000

[Psychiatric emergency service in a university general hospital: a prospective study].

OBJECTIVES: The aim was to carry out a prospective study about the characteristics of the public seen at a psychiatric emergency room and of its service. METHODS: The data were acquired though a protocol developed for this study and applied to all the patients seen during two months. RESULTS: 600 protocols were filled out, corresponding to 96.5% (487 patients) of the attendance during the study period. Most of the patients seen were males, single, with a low educational level, professionally inactive and living with their families. The most frequent diagnoses were psychoactive substance use disorders (26.3%), schizophrenia (15.5%), manic episode (11.8%), major depression (10.9%) and non-psychotic disorders (10.9%). There were differences between gender in some diagnostic categories. After initial evaluation, 2/3 were medicated, (1/2) stayed under observation, and (1/4) stayed more than 10 hours in the service unit. About 20% of the attendance resulted in hospitalization and 60% in referrals to outpatient services. Discharges due to evasion represented only 2.0% of the total. Returning service users did not differ from those seen only once to what concern marital status, professional situation and household conditions. However, returning users presented a higher frequency of previous hospitalization and psychotic disorders. CONCLUSIONS: Individuals with severe psychiatric disorders were seen in an actual emergency situation. The psychiatric emergency service has been expanding its actions and has been an effective part of the mental health service network.

Adult↗
PubMed1993

[Outpatient ESWL in 500 kidneys].

Between March 1989 and January 1992, 600 cases (636 kidneys) with upper urinary tract stones were treated with ESWL, using a Lithostar. Of these, 78.6% were carried out in our outpatient service, and in the last two years approximately 90% of cases have been treated as outpatient. We evaluated first 500 kidneys, treated with ESWL as outpatient. There were 481 cases involving 500 kidneys (19 bilateral cases). The ages of the 367 men and 114 women ranged from 16 to 77 years. There were 227 kidney stones and 273 ureter stones. Most of the stones were less than 20 mm. The average number of sessions and shock waves for each patient were 1.4 times and 6,988 waves, respectively. While 74% of the patients could be treated in only one session, 9% of them needed 3 sessions or more. Auxiliary measures were needed in 23 cases (D-J stent insertion in 5 cases and ureteral catheterization in 18 cases) and 474 cases (94.8%) were treated by in-situ procedures. At 3 months after treatment, 470 cases were evaluated and the stone-free rates of kidney stones and ureter stones were 70.3% and 84.5%, respectively with an overall stone-free rate of 78.1%. With regard to complications, the rate of the clinic visit because of pain after treatment was observed in 4.6% and higher than 38 degrees C in 2.5%. However, no serious perioperative complications occurred. From these results, outpatient ESWL was considered to be safe and efficient without serious complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Is there a market for regional units in child and adolescent psychiatry?

BACKGROUND: An analysis of the demand for the services of a sub-regional Family and Young Persons Unit which offers both in-patient and out-patient treatment for children and adolescents with psychiatric, emotional or psychological problems was performed. METHODS: Interviews were held and questionnaires were sent to representatives of the principal and potential users of the service both within the local district and beyond. RESULTS: The results demonstrated unmet demand for outpatient services but only limited demand for in-patient services in some districts. The role of market research in the new National Health Service and some of the difficulties of applying it are discussed. The implications of the findings for both the Family and Young Persons Unit and for child and adolescent psychiatry are considered. CONCLUSION: It is concluded that the effect of the market may be to bring about the closure of regional units unless there is intervention to protect them.

Adolescent↗
PubMed1991

Ambulatory care to drive hospital services in 1990s.

Health care providers can expect a dramatic change in ambulatory care in the next decade. Driven by a variety of factors, including double digit growth in key outpatient areas, hospital administrators can expect a continuation of a trend that began in the 1980s. In the following article, the author details the changes that will focus on outpatient services.

Ambulatory Care↗
PubMed1976

The role of the certified social worker in England's social services.

With the reorganization of England's social services into a single unified system, the professional called the certified qualified social worker is playing a key role in the administration and delivery of community services. The author describes some of the worker's activities and also presents an overview of hospital, day treatment, and outpatient services for adult psychiatric patients in the county of Warwickshire. One of the most effective programs is a system of voluntary group homes, operated by an area council of churches, for former psychiatric inpatients.

Aftercare↗
PubMed2005

The use of direct clinician observation and vignettes for health services quality evaluation in developing countries.

This paper reports the results of a comparison between two different methods of examining quality in outpatient services in a developing country. Data from rural and urban Tanzania are used to compare the measures of quality collected by direct clinician observation (DCO) (where clinicians are observed in the course of their normal consultations) and vignettes (unblind case studies with an actor). The vignettes are shown to exhibit a strong connection between the inputs provided during consultation (rational history taking, physical examination and health education) and the ability of the clinician to properly diagnose the presented illness. However, the inputs provided in vignettes are not well correlated with the inputs provided in DCO, suggesting that the inputs provided in the vignette are not well correlated with the inputs that would be provided in an actual consultation. We conclude that since vignettes do not appear to be measuring what would be provided in an actual consultation they are not a good measure of quality. Instead, we suggest that vignettes and DCO be used simultaneously. We show how the scores obtained using vignettes in conjunction with DCO can be used to improve the reliability of DCO and therefore our estimates of actual clinician quality.

Clinical Competence↗
PubMed2000

Predicting health services utilization among homeless adults: a prospective analysis.

This study expands on the Andersen-Newman health services utilization (HSU) model. In a community-based homeless sample (n = 363) baseline predisposing, enabling, and needs-based variables predicted hospitalization and ambulatory outpatient service utilization within 1 year after baseline. Standard predisposing and enabling variables were supplemented with latent constructs representing substance use, mental illness, poor housing status, social support, community support, and barriers to health care. Need is represented by baseline health status. Poor physical health, more barriers, drug use, African American ethnicity, less community support, and less education predicted hospitalization, the least desirable form of HSU. Poor health, female gender, a regular source of care, community support, drug use, and fewer alcohol problems predicted an office visit. Because outpatient visits for acute conditions provide an opportunity for generally neglected preventive services and health screenings, this study suggests convenient multiservice health-related programs for the homeless that include drug and alcohol treatment.

Adolescent↗
PubMed2004

Patient anxiety and experiences associated with an outpatient "one-stop" "see and treat" hysteroscopy clinic.

BACKGROUND: "One-stop" outpatient hysteroscopy clinics have become well established for the investigation and treatment of women with abnormal uterine bleeding. However, the advantages of these clinics may be offset by patient factors such as anxiety, pain, and dissatisfaction. This study aimed to establish patients' views and experiences of outpatient service delivery in the context of a one-stop diagnostic and therapeutic hysteroscopy clinic, to determine the amount of anxiety experienced by these women and compare this with other settings, and to determine any predictors for patient preferences. METHODS: The 20-item State-Trait Anxiety Inventory was given to 240 women attending a one-stop hysteroscopy clinic: to 73 consecutive women before their appointment in a general gynecology clinic and to 36 consecutive women attending a chronic pelvic pain clinic. The results were compared with published data for the normal female population, for women awaiting major surgery, and for women awaiting a colposcopy clinic appointment. In addition, a questionnaire designed to ascertain patients' views and experiences was used. Logistic regression analysis was used to delineate the predictive values of diagnostic or therapeutic hysteroscopy, and to determine their effect on the preference of patients to have the procedure performed under general anesthesia in the future. RESULTS: Women attending the hysteroscopy clinic in this study reported significantly higher levels of anxiety than those attending the general gynecology clinic (median, 45 vs 39; p = 0.004), but the levels of anxiety were comparable with those of women attending the chronic pelvic pain clinic (median, 45 vs 46; p = 0.8). As compared with the data from the normal female population (mean, 35.7) and those reported for women awaiting major surgery (mean, 41.2), the levels of anxiety experienced before outpatient hysteroscopy clinic treatment were found to be higher (mean, 45.7). Only women awaiting colposcopy (6-item mean score, 51.1 +/- 13.3) experienced significantly higher anxiety scores than the women awaiting outpatient hysteroscopy (6-item mean score, 47.3 +/- 13.9; p = 0.002). Despite their anxiety, most women are satisfied with the outpatient hysteroscopy "see and treat" service. High levels of anxiety, particularly concerning pain but not operative intervention, were significant predictors of patients desiring a future procedure to be performed under general anesthesia. CONCLUSIONS: Outpatient hysteroscopy is associated with significant anxiety, which increases the likelihood of intolerance for the outpatient procedure. However, among those undergoing operative therapeutic procedures, dissatisfaction was not associated with the outpatient setting.

Adult↗
PubMed1999

Payer costs of patients diagnosed with epilepsy.

PURPOSE: To identify the annual cost to a third-party payer of inpatient and outpatient services and prescription drugs for patients diagnosed with epilepsy or convulsions. METHODS: Retrospective study using administrative and claims data from a private insurer in the Northeast United States with >1.8 million covered lives. Health plan members were included if they had a claim for epilepsy or convulsions and a claim for an antiepileptic drug (AED) between January 1992 and December 1996. Annual costs and frequencies of all medical services, and of services related to epilepsy, were compared among five groups of patients defined by the most intensive procedure they received: invasive therapeutic procedure (group 1); invasive diagnostic procedure without an invasive therapeutic procedure (group 2); noninvasive diagnostic procedure without an invasive procedure (group 3); neurologist or neurosurgeon visit without an invasive procedure or noninvasive diagnostic procedure (group 4); or none of the preceding services (group 5). RESULTS: In the cohort of 9,090 patients meeting the inclusion criteria, mean age was 38 years, 53% were female, 30% had malignant disease, and 25% had cardiac disease. The mean annual cost of all medical services was $9,617. Mean annual costs of all services were $43,333, $29,847, $11,300, $4,362, and $5,855, and annual costs of inpatient and outpatient encounters coded as epilepsy plus AEDs were $24,369, $10,330, $3,127, $1,079, and $1,086, in groups 1-5, respectively. Services used to stratify patients into the groups accounted for 37% of the total costs. CONCLUSIONS: The annual costs of medical services for patients with epilepsy are high and vary considerably because of treatment of epilepsy and management of comorbidities.

Adult↗