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PubMed1998

Hospital-based rehabilitative care versus outpatient services: effect on functioning and health status.

PURPOSE: The goal of this clinical trial was to examine the long-term impact of rehabilitative care on the health status of patients diagnosed with a disabling disorder. METHOD: Study patients consisted of first-time hospitalizations from diagnostic groups commonly admitted for inpatient rehabilitation, including nervous, circulatory, and musculoskeletal disorders or injury. Patients were randomly assigned to inpatient rehabilitation (n = 43) or to outpatient follow-up (n = 42) in which the usual medical services were provided but no scheduled rehabilitative therapies were offered. Specific objectives of the study were to determine the effects of impatient rehabilitation on: (1) functional ability, (2) health and mental health status, (3) personal adjustment, and (4) family function. Cost and use of health-care resources were descriptively assessed. RESULTS: Analysis of covariance found no significant treatment effects, either at 6 months or at 1 year, for any of the variables under study. In addition, there were no differences between groups in their use of nursing homes, length of hospital stay, mortality, or in the number of hospital readmissions or clinic visits during the first year after hospital discharge. Use of rehabilitation services and cost of care was significantly higher than outpatient services. The findings were consistent with previous studies for most outcomes, with the major exception being functional improvements. Contrary to earlier studies, rehabilitation was not found to effectively produce lasting functional outcomes. However, study conditions may not have fully corresponded to those of previous studies, and further research is needed. The patient sample was representative of a full inpatient service and therefore more heterogeneous than samples reported in prior studies, but the small sample size (due to reductions in the number of admitted patients to the rehabilitation unit during the course of the study) precluded subgroup analysis of diagnostic groupings. CONCLUSION: The findings suggest that hospital-based rehabilitative care does not have lasting benefits, and that alternative care or supportive follow-up by a subacute-care facility may be needed to assist patients in maintaining functional gains and health benefits.

Adult↗
PubMed1995

Information as a fundamental attribute among outpatients attending the nuclear medicine service of a university hospital.

The aim of this study was to assess outpatients' satisfaction with the service received in the nuclear medicine service of the Hospital Clinic i Provincial of Barcelona in February 1993. The patients were randomly assigned to one of two groups: group 1 received information about their diagnostic procedure, whereas group 2 did not (a control group). A questionnaire was used to assess patients' degree of satisfaction. The questionnaire was administered to 803 patients, 243 (30.26%) of whom completed it and returned it. The following factors were significantly related to high scores on the satisfaction scale: age (P < 0.015), waiting time (P < 0.001), treatment by assisting personnel (P < 0.001), treatment by personnel at the service reception (P < 0.01), waiting room habitability (P < 0.01), communication variables (P < 0.03) and low scores on the anxiety scale (P < 0.02). Group 1 perceived more positively treatment by personnel at reception (P < 0.041), treatment by assisting personnel (P < 0.027), waiting room habitability (P < 0.035) and communication variables (P < 0.001). The anxiety scale scores among this group were significantly lower. We conclude that when information is supplied to patients, their anxiety decreases before a diagnostic procedure, which significantly improves their perception of the factors that generate satisfaction among patients.

Adolescent↗
PubMed1994

Managing orthopedics and neurosciences costs through standard treatment protocols.

High-cost, high-volume specialty programs such as orthopedics and neurosciences find themselves in a position of evaluating the costs and in some cases the appropriateness of medical practices in response to payer scrutiny and provider selection processes. Orthopedics and neurosciences programs are at a stage of development analogous to that of cardiovascular care several years ago. Many of the same trends have come into play, such as payer "carve-outs" for orthopedic services, payer selection of centers of excellence based on cost and quality, reduction of Medicare reimbursement, greater use of high-cost technology, the decline of profitability due to "older, sicker, and tougher" patients, and the recent emergence of national orthopedic specialty networks oriented to national contracts for care. In an era in which payers demand value on both sides of the cost-plus-quality equation, programs are challenged to maximize the return on a patient population rife with "no-win" situations. In the orthopedic service line these include a high proportion of Medicare patients and chronic conditions such as workers' compensation medical back cases or repetitive motion injuries, which can be elusive to diagnose and expensive to treat. Many hospitals continue to lose money on joint replacement surgeries, the largest-volume orthopedic inpatient service, primarily because of the high Medicare population and the cost of implants. Neuroservices, while still relatively well reimbursed, face a rising proportion of Medicare payments as patients live longer and develop chronic, degenerative conditions. Inpatient days are decreasing due to payer pressures to limit hospital stays and to shift inpatient care to outpatient services. Some hospitals "have lost interest in (the orthopedic) service line during the last five years because of recent trends in orthopedic-related inpatient volume and payment." But by managing costs strategically, both the neurosciences and orthopedics service lines can provide substantial revenue as well as the opportunity to achieve a "center of excellence" competitive position in a managed care environment. This Special Report outlines the process and advantages of managing costs and quality of care strategically, that is, in a manner which helps these programs meet internal cost and clinical goals while responding to market situations. The hospital, physicians, and patients all benefit as costs are reduced, quality is enhanced, and the service line's competitive position is strengthened.

Cost Control↗
PubMed2006

Evaluation of clinical pharmacy services in a hematology/oncology outpatient setting.

BACKGROUND: The Veterans Affairs North Texas Health Care System in Dallas, TX, provides a unique opportunity for clinical pharmacists to work as providers. Even though clinical pharmacists are actively involved in patient care, many of their efforts remain undocumented, resulting in an underestimation of the importance of their services and missed opportunities for improvements and new directions. OBJECTIVE: To document and evaluate the services of a hematology/oncology clinical pharmacy in the outpatient setting. METHODS: Pendragon Forms 3.2 software was used to design the documentation template. The template was designed to collect diagnoses, supportive care issues, drug-specific interventions, and prescriptions written. This template was uploaded to the personal digital assistant (PDA) for documentation. Patient-specific information was documented in a password-protected PDA. Data collected from November 1, 2002, to October 31, 2003, were retrospectively analyzed. RESULTS: Clinical pharmacists were involved in 423 patient visits for chemotherapy follow-up or disease management. Cancer diagnoses included colorectal (n = 99), multiple myeloma (59), non-small cell lung (56), chronic lymphocytic leukemia (44), myelodysplastic syndromes (22), and chronic myelogenous leukemia (19). During the 423 patient visits, 342 supportive care issues were addressed including anemia (34%), pain management (22%), constipation/diarrhea (15%), and nausea/vomiting (8%). Major drug-specific interventions included drug addition (41%), discontinuation (23%), and adjustment (21%). Four hundred forty-five prescriptions were filled, of which 181 were new and 150 were refilled. CONCLUSIONS: This is the first study, as of July 25, 2006, to document considerable contribution of an outpatient clinical pharmacist in direct cancer patient care. Although the disease management and supportive care issues addressed here may differ based on institution and patient population, the results of our study show that clinical pharmacists have ever-growing roles in the management of these patients.

Ambulatory Care↗
PubMed1996

Pattern of outpatient laboratory service consumption in a teaching hospital in Gondar, Ethiopia.

A one year laboratory service analysis for outpatient service consumers of Gondar College of Medical Sciences Hospital was done. Data were gathered through a daily registry prospectively. 17,471 patients visited the laboratory between October 1994 and September 1995. 47.9% were from Gondar town. 72.5% paid for the services. Children under 15 made up only 11.8% of service consumers. In the year, a total of 27,982 laboratory tests were requested, 48% of which were in urinalysis and parasitology. Most of the requests could be handled by upgraded peripheral laboratories leaving room for the unit to act as a training and back-up centre.

Adolescent↗
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↗
PubMed1996

Day hospital/crisis respite care versus inpatient care, Part II: Service utilization and costs.

OBJECTIVE: The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program. METHOD: The patients (N = 197) were randomly assigned to one of the two programs and followed for 10 months after discharge. Both programs were provided by a community mental health center (CMHC) in a poor urban community. Data were collected for developing service utilization profiles and estimates of per-unit costs of the inpatient, day hospital, and outpatient services provided by the CMHC. RESULTS: On average, the day hospital/crisis respite program cost less than inpatient hospitalization. The average saving per patient was +7,100, or roughly 20% of the total direct costs. There were no significant differences between programs in service utilization or costs during the follow-up phase. Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter. Significant differences in cost were found among patient groups with psychosis, affective disorders, and dual diagnoses; psychotic patients had the highest costs in both programs. The two programs had roughly equal direct service staff and capital costs but significantly different operating costs (day hospital/crisis respite operating costs were 51% of inpatient hospital costs). CONCLUSIONS: The programs were equally effective, but day hospital/crisis respite treatment was less expensive for some patients. Potential cost savings are higher for nonpsychotic patients. Cost differences between the programs are driven by the hospital's relatively higher overhead costs. The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for understanding why these programs provided equally effective acute care.

Adult↗
PubMed1999

Specialist palliative care and patients with noncancer diagnoses: the experience of a service.

This retrospective review was undertaken to identify the pattern of noncancer referrals to a specialist palliative care service, comprising a teaching hospital support team, home care, outpatients and inpatient hospice, over a 1-year period. Of 287 hospital ward referrals, 83 patients had a noncancer diagnosis (29%); they were referred predominantly for symptom control (92%), particularly of pain (84%). Of 130 outpatient referrals, 30 had a noncancer diagnosis (23%) and were also referred mainly for the management of pain (85%). Of 196 home care referrals, 18 had a noncancer diagnosis (9%); they tended to be referred for multiprofessional care of endstage disease. Of 421 hospice inpatient admissions, 17 were for patients with a noncancer diagnosis (4%) and were predominantly for respite care. These admissions accounted for 2% of occupied bed days. It is concluded that specialist palliative care skills are perceived to be transferable to patients with noncancer diagnoses. Resource implications focus on hospital and outpatient services, where shared care with medical teams is usual practice. Defining management goals at the outset is particularly important.

Adult↗
PubMed1993

Antitrust pitfalls in outpatient services.

Increasingly, services traditionally provided to inpatients are moving to the outpatient setting, resulting in greater antitrust risk. Antitrust issues are most likely to arise when a hospital with a large share of the inpatient market attempts to increase outpatient volume by restricting their patients' choices of outpatient providers, or when providers who control scarce outpatient resources attempt to restrict competition by denying other providers access to a facility. This trend has affected physicians both as competitors of hospitals in the outpatient services market and as participants with hospitals in ventures for the provision of outpatient care.

Ambulatory Care↗