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PubMed1975

Adopting new models for continuity of care: what are the needs?

There are glaring, almost universal deficiencies in the organization of community resources for treating and rehabilitating the mentally ill, particularly psychotic patients, the author says. The deficiencies could be partly remedied by reorganizing psychiatric hospitals to play a key role in outpatient service delivery, and by paying more attention to the principles of continuity of care for psychotic patients. One way of doing both is through the model of a mini-mental-health-center adopted at a Veterans Administration hospital: the same terms provide active, continual care for patients regardless of whether they are in or out of the hospital. The program developed on one ward is described further in the next paper, written by ward staff members and others.

Community Mental Health Services↗
PubMed2001

An audit of the ophthalmic division of the accident and emergency department of the Royal Victoria Eye and Ear Hospital, Dublin.

The objective was to study the patterns of emergency department visits and to make recommendations on ways of improving the service. Patients' demographic data, diagnoses, source of referral and follow-up were entered onto a database. Three thousand seven hundred consecutive patients' visits over a six-week period were entered. The average daily attendance ranged between 80-100 people. 54% of patients were self-referrals. 20% had a previous visit to the hospital. 17% were referred from a GP, 5% from another hospital and 3% from opticians. Superficial injury to the eye and ocular adnexae was the most common diagnostic category. 56% of patients were discharged at the first visit. 23% returned for review to casualty. 14% were referred to OPD, 3% directly to a consultant for review and 1% were admitted to hospital. Waiting times for consultation for patients was highly variable ranging from thirty minutes to five hours, mean two hours. The department provides a service far in excess of its defined function. Non urgent problems accounted for as much as 60-70% of all emergency department visits. Improvement of ophthalmic training of GPs, introduction of an ophthalmic triage system and expansion of outpatient services is recommended so that casualty remains a genuine emergency service and not a primary care service with uncontrollable numbers and unacceptable waiting times for patients.

Emergency Service, Hospital↗
PubMedDate not supplied

Economic and gastrointestinal safety comparisons of etodolac, nabumetone, and oxaprozin from insurance claims data from patients with arthritis.

This study was conducted to compare the effect of etodolac, nabumetone, and oxaprozin use on gastrointestinal (GI) safety and associated costs based on insurance claims information from practice settings. Data were obtained from a national claims database (MarketScan) for the years 1992 to 1994. The claims data of interest were for patients with arthritis who had used etodolac, nabumetone, or oxaprozin exclusively during a 9-month follow-up period (ONLY groups), or these drugs plus (PLUS groups) the other nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen, naproxen, diclofenac, sulindac, piroxicam, ketoprofen, or indomethacin. For each group, we obtained information on the use of inpatient and outpatient services for GI-related events and the associated costs. All GI admissions were classified as NSAID-induced or possibly NSAID-induced events based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) codes. All outpatient upper GI ulcers or bleeding episodes were also identified by specific ICD-9 CM code. There were no significant between-group demographic differences. The proportions of patients with NSAID-induced and possibly NSAID-induced GI admissions were 0.1% and 0.4% for the etodolac-ONLY, 0.3% and 1.0% for the nabumetone-ONLY, and 0.1% and 0.5% for the oxaprozin-ONLY groups, respectively (P > 0.05), and a similar pattern was observed among the PLUS groups. In outpatient settings, 3.9%, 4.2%, and 4.9% of the etodolac-, nabumetone-, and oxaprozin-ONLY patients, respectively (P > 0.05), and 6.0%, 5.3%, and 4.7% of the etodolac-, nabumetone-, and oxaprozin-PLUS patients, respectively, had at least one upper GI ulcer/bleeding claim (P > 0.05). The total health care costs for 9 months were approximately $3000 each for the etodolac-, nabumetone-, and oxaprozin-ONLY groups. Oxaprozin, nabumetone, and etodolac had similar GI-safety and associated-costs profiles based on information from practice settings. Also, in patients who used multiple NSAIDs, the groups did not differ in their GI-safety and cost profiles.

Adult↗
PubMed1987

Health insurance and the demand for medical care: evidence from a randomized experiment.

We estimate how cost sharing, the portion of the bill the patient pays, affects the demand for medical services. The data come from a randomized experiment. A catastrophic insurance plan reduces expenditures 31 percent relative to zero out-of-pocket price. The price elasticity is approximately -0.2. We reject the hypothesis that less favorable coverage of outpatient services increases total expenditure (for example, by deterring preventive care or inducing hospitalization).

Analysis of Variance↗
PubMed1991

[Utilization of the National Hospital 1985-89. How many beds should there be in a new National Hospital?].

The Norwegian Parliament (Stortinget), has approved a proposal for construction of a new national hospital in Oslo. White Paper no. 38 (1987/88) proposes a hospital with 610 beds. The number of inpatient days at the present Rikshospitalet (The National Hospital) has declined by 19.4% during the period 1985 to 1989. In 1989 the use of inpatient services was equivalent to 530 beds with an occupancy rate of 80%. Based on an assumed further reduction in hospital use in the years to come, we estimate the need for beds to be 340 at the new national hospital. This lower number is assumed to cover local hospital functions (54 beds), regional hospital functions (220 beds) and national services (65 beds). The authors assert that the White Paper is based on outdated assumptions. The construction of a 610-bed national hospital involves a health care structure which could obstruct the reorganization of hospital care (more use of outpatient services) elsewhere in Norway. The County Councils responsible for financing hospitals will be forced to fund a hospital use that is motivated essentially by teaching and research rather than by caring for patients.

Bed Occupancy↗
PubMed2004

Geographical proximity and health care utilization in veterans with SCI&D in the USA.

In the USA, substantial geographic variation in health care utilization exists in the Department of Veterans Affairs (VA) health care system. Utilization of health care services is especially important for veterans with spinal cord injuries and disorders (SCI&D) who are often at high risk for secondary complications related to their SCI&D. Due to impaired mobility, access to health care for veterans with SCI&D may be even more challenging. The goal of this cross-sectional study was to describe health care utilization relative to SCI&D veteran residential geographic proximity to VA health care facilities. A negative binomial regression model was used to examine VA outpatient utilization. Veterans with SCI&D utilized outpatient services less frequently when VA facilities were farther away from their residences (p<0.000). Female (p<0.000), older (p<0.000), and non-white veterans (p<0.000), and veterans with history of respiratory (p<0.000), kidney/urinary tract (p<0.005), circulatory (p<0.000), or digestive system diseases (p<0.003) were more likely to utilize outpatient care during the study period. A Poisson model was used to examine inpatient utilization. Inpatient utilization decreased when travel distance to VA facility increased (p<0.000). Contrary to outpatient, age did not significantly affect veterans' likelihood of using inpatient health care. Marital status, gender, race, and level of injury were not related to inpatient utilization. However, history of prior illnesses including respiratory (p<0.000), kidney/urinary tract (p<0.000), circulatory (p<0.005), digestive system (p<0.015), or skin/subcutaneous tissue/breast-related illnesses (p<0.000) were associated with a greater likelihood of inpatient utilization. Geographic proximity and other factors on health care use must be considered in order to meet the health care demand patterns of veterans with SCI&D.

Cross-Sectional Studies↗
PubMed2001

A case-control for the association between change in weight, family history and hypertension at different ages.

To study the association between the changes of weight, family history and hypertension at different ages, a pair-matched case-control study was conducted in the outpatient service of department of internal medicine in Binjiang Hospital of Tianjin from 1994 to 1996. The cases were selected from 312 patients with hypertension diagnosed during 1994-1996 and identified newly in the survey. The controls were selected from other outpatients of no cardiovascular disease histories matched by age and sex. The conditional logistic regression model was used. The cases and controls were divided into two age groups under 59 years old, 60 and older. History of hypertension in the first degree-relatives was linked to hypertension, but family history of hypertension of groups under age 59, and at 60 and older was mainly hypertension history of parents and siblings, respectively. Other risk factors of developing hypertension were higher weight or body mass index (kg/m2) in the survey, higher degree of weight gain in comparison with the basic weight and early age at beginning weight gain in all two groups. However, the risk of developing hypertension for increasing weight and obesity increased with advancing age groups. The study further indicates that controlling body weight, decreasing the degree of weight gain, and delaying the beginning age of weight gain all contribute to the lower risk of suffering from hypertension and were effective measures of hypertension of the prevention and cure.

Age of Onset↗
PubMed1993

Clozapine: an appraisal of its pharmacoeconomic benefits in the treatment of schizophrenia.

Clozapine, an antipsychotic agent with relatively weak central antidopaminergic activity, displays atypical pharmacological and clinical properties vis-a-vis the classic antipsychotics. Thus, clozapine is effective against both the positive and negative symptoms of schizophrenia and has a low propensity to cause extrapyramidal effects. Furthermore, clozapine is effective in a substantial proportion (up to 60%) of patients who are refractory to or intolerant of standard antipsychotic therapy. Despite its promising therapeutic potential, the relatively high incidence of clozapine-induced agranulocytosis (approximately 1% of patients) and the associated need for regular haematological monitoring currently restricts the drug's use to the treatment of chronic and severe schizophrenia refractory to standard antipsychotic therapy, and to those patients unable to tolerate such therapy. In the US, the current wholesale price of clozapine (exclusive of monitoring) is $US2.85 per 100mg tablet, amounting to $US4160 annually (1992 dollars) at the most commonly prescribed dose of 400 mg/day ($US2.40 per tablet and $US3510 annually to state programmes through Medicaid reimbursement legislation). In the UK, the annual cost of clozapine (at the average dose of 300 mg/day), inclusive of blood monitoring, is 1806 British pounds sterling (1992 pounds). Although the acquisition cost of clozapine is high in comparison with that of standard antipsychotics, preliminary cost-effectiveness estimates in patients with treatment-resistant schizophrenia suggest that the clinical benefits of the drug (viz. improved psychopathology, social functioning and quality of life) may confer medium to long term economic benefits, primarily by reducing the need for psychiatric hospital services. This effect is most likely to be seen on long term ( greater than or equal to 2 years) maintenance therapy with clozapine. Savings in hospital costs are, however, likely to be offset, at least initially, by increased reliance on outpatient services, and clozapine may therefore confer additional economic costs during the first year or so of treatment. In the longer term, however, the initial cost investment may be recouped in the form of savings to psychiatric institutions and insurers.

Clozapine↗
PubMed1989

Development of an outpatient utilization review program.

Usage of outpatient services has reached an all time high. Insurers and employers seek means to monitor the escalating costs for providing ambulatory care. This article offers insight about the objectives of managed care groups and what they are looking for in their outpatient utilization review endeavors.

Ambulatory Care↗
PubMed1975

Severity of symptoms of psychiatric outpatients: use of the General Health Questionnaire in hospital ang general practice patients.

A sample of 91 new referrals to a community based psychiatric outpatient service was compared with a cross-matched control sample of 107 patients attending the general practitioner's surgery. The subjects in both groups completed the General Health Questionnaire and there was a very marked difference between the scores of the two groups. Seventy-five of the psychiatric group had a high score on the questionnaire, and a large number of these were extremely high, while 74 of the general practice group had a low score. The 'false' positives and negatives are discussed. It is considered that the validity of this questionnaire as a screening device for demonstrating psychiatric morbidity and severity in general practice is further established in this study by showing that in matched samples the expected psychiatric morbidity in general practice can be compared with the much greater morbidity in psychiatric outpatient referrals. For the psychiatric sample more patients showed high scores and these tended to be much higher.

Adjustment Disorders↗
PubMed1997

Improving outpatient clinic efficiency using computer simulation.

To assess and plan alterations in outpatient clinic structure, produces a computer simulation of an outpatient clinic based on detailed time and role measurements from the authors' clinic. The stimulation which used an object-oriented design method is able to indicate the impact of changes in clinic structure using patient and doctor waiting times in clinic as endpoint measures. The effects of changes in clinic size, consultation time, patient mix, appointment scheduling and non-attendance were examined. We found that patient waiting time could be shortened considerably by using an optimizing appointment scheduler to determine appointment intervals. Clinic mix influences patient waiting time, which was shorter with a 1 in 4 ratio of new to follow-up patients. In mixed clinics, new patients appointments are optimally spread throughout the clinic to reduce patient waiting time. In all new or all follow-up clinics, waiting time is improved if the appointment interval reflects the consultation time. Computer modelling can help in optimizing clinic management so improving the delivery of care in outpatient services.

Appointments and Schedules↗
PubMed1993

A systematic study of mental health services utilization by homeless men and women.

Psychiatric illness is overrepresented among the homeless, but mental health services are underutilized in this population in proportion to their needs. The current study was concerned with 900 homeless men and women randomly sampled and systematically interviewed with the Diagnostic Interview Schedule; it focuses on psychiatric and substance abuse rehabilitation service patterns and stated needs of this population in relation to specific psychiatric disorders. Although rates of lifetime treatment utilization were fairly high in comparison with general population utilization patterns, rates of treatment in the current year were low. In particular, outpatient services have been neglected for reliance upon inpatient services. Although the major reason cited for not obtaining treatment by homeless persons with mental illness was lack of insurance and inability to pay for it, having health insurance was not associated with mental health services utilization, nor were other important predictors apparent. Mental health professionals serving mentally ill homeless populations would best serve them by focusing on creative and innovative ways to improve the availability and attractiveness of ambulatory care services.

Adolescent↗
PubMed1995

The relationship between supply and hospitalization rates for mental illness and substance use disorders.

This study investigated the extent to which mental illness and substance use hospitalization rates were related to the supply of psychiatric treatment services. Supply variables, notably the per capita rate of psychiatrists, primary care physicians, and specialty units, were strongly related to mental illness and substance use hospitalization rates to acute care hospitals across 114 small geographic areas in Iowa. The supply of outpatient services was not related to hospitalization rates. The need to study the reliability of patient assessment processes, refine guidelines and admissions criteria, and understand the contributions of supply variables to hospitalization rates are indicated by these results. A conceptual model is offered within which the dynamic cycle from patient functioning to service delivery may be framed.

Data Collection↗
PubMedDate not supplied

[Patient and their relatives' satisfaction regarding a home-based crisis intervention provided by a mobile crisis team].

The goal of this survey was to evaluate the patients and their relatives' satisfaction with a home-based crisis intervention provided by a psychiatric mobile crisis team (Equipe Rapide d'Intervention de Crise, hôpital Charcot, Plaisir). We were particularly interested in measuring satisfaction with telephone response time, team mobility, patient welcome, family consultations, information given to patients and the number of caregivers. We designed a questionnaire that included 24 closed questions and 2 open-ended questions. Replies were collected over the telephone by an outside psychologist with no prior knowledge of the patients. The inclusion criteria were the following: the patient had to have received a home-based crisis intervention from the mobile crisis team and to have received at least two follow-up consultations. The response rate was 95%, from 81 relatives and 73 patients. The results show a high level of overall satisfaction, with satisfaction levels at over 90% for some of the questions. High satisfaction was due to the human and professional approach of staff - their listening skills and competence - the 24-hour availability of the telephone service, the fast intervention of the team, the team mobility, and the systematic involvement of relatives as part of the program. Low satisfaction was due to the high number of caregivers, the short length of programs, the patient referral process to outpatient services, the lack of information on medication and patients' illness and the sad appearance of the building. These results lead us to improve some aspects of our service or at least to explain our services more fully to clients. More generally, these results encourage us to listen more attentively to patients' opinions on how they experience their psychiatric care.

Adult↗
PubMed1994

Feasibility and efficacy of intensive insulin therapy in type 1 diabetes mellitus in primary care.

To determine the feasibility and efficacy of structured education in intensive insulin therapy (IIT) in patients with Type 1 diabetes mellitus commonly attended by primary care physicians, a prospective case-control study was carried out in co-operation with 26 general practitioners in rural Alpine region and the diabetes service at the University of Vienna, Medical School, Austria. From 89 rural Type 1 diabetic patients on conventional insulin therapy (CIT), those volunteering for better diabetes care (n = 52) were trained in IIT in the diabetes education centre and subsequently received their outpatient service by their general practitioners, as did those remaining on CIT (n = 37). Patients were matched as case-controls (n = 36 in each therapy group) for metabolic control at baseline (IIT/CIT: HbA1c 8.2 +/- 1.8 vs 8.1 +/- 2.0%, ns), age, duration of diabetes, incidence of retinopathy and nephropathy. Analysing an observation period of > 4.5 years, patients trained in IIT presented with improved metabolic control as compared to those on CIT (Mean HbA1c: IIT, 6.9 +/- 1.0%; CIT, 7.9 +/- 1.3%, p < 0.05, ANOVA). No difference between groups was, however, observed at the end-point of the study in HbA1c (IIT, 7.3 +/- 1.3%; CIT, 7.8 +/- 1.4%; IIT vs CIT, p = 0.14) and in the development of diabetic microangiopathy, frequency of reported severe hypoglycaemic episodes, and increase in body weight.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMedDate not supplied

Redesigning emergency care: financial and cost analysis of services provided.

Developing an interdiscliplinary team to monitor and implement redesign is critical to successful, quality outcomes. Analysis of the current status of the organization and national trends is essential prior to redesign. Key assessment data gathered were: profiling users, payer distribution, inpatient admissions, data on types of chronic conditions, DRGs, readmits, short-stay admissions, non-admits, and outpatient services and charges. Organizational realignment requires time and analysis of financial, clinical, and demographic data. The team-building framework used in this emergency room redesign was based on a collaborative model. A crucial initial step was to get support from the organization's executive level of leadership for the new redesign vision. Another factor considered essential for a successful outcome was commitment from each member of the interdisciplinary team. Communication between the team and staff was a top priority.

Costs and Cost Analysis↗
PubMed1999

Health care utilization by older patients with coexisting dementia and depression.

OBJECTIVE: Few studies have examined the course of coexisting dementia and depression. The purpose of this study was to compare elderly patients who had coexisting dementia and depression with elderly patients who had either disorder alone in terms of their utilization of inpatient and outpatient services. METHOD: The study group included 7,115 veterans aged 60 years or older who had been discharged from Department of Veterans Affairs inpatient units in 1992 with diagnoses of major depression, dementia, or both. Outcome measures were analyzed for a 2-year period following the index hospitalization for each diagnostic study group. RESULTS: Patients with coexisting dementia and depression had significantly more psychiatric inpatient days than the other two study groups and more medical inpatient days and nursing home readmissions than patients with depression alone. Patients with coexisting dementia and depression had significantly more total inpatient days than the other two groups. Notably, patients with coexisting dementia and depression did not utilize more outpatient resources than the other study groups; in fact, they had significantly fewer medical, psychiatric, and total visits than patients with depression alone. CONCLUSIONS: The findings suggest that patients with coexisting dementia and depression are high utilizers of inpatient services, with a course of illness that may resemble dementia in terms of nursing home and inpatient medical care utilization and depression in terms of inpatient psychiatric care utilization; however, these patients utilized significantly fewer outpatient resources than the group with depression alone. Aggressive outpatient treatment approaches might reduce utilization of inpatient care for patients with coexisting depression and dementia.

Age Factors↗