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PubMed2001

UPBEAT: the impact of a psychogeriatric intervention in VA medical centers. Unified Psychogeriatric Biopsychosocial Evaluation and Treatment.

BACKGROUND: The Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) program provides individualized interdisciplinary mental health treatment and care coordination to elderly veterans whose comorbid depression, anxiety, or alcohol abuse may result in overuse of inpatient services and underuse of outpatient services. OBJECTIVES: To determine whether proactive screening of hospitalized patients can identify unrecognized comorbid psychiatric conditions and whether comprehensive assessment and psychogeriatric intervention can improve care while reducing inpatient use. DESIGN: Randomized trial. SUBJECTS: Veterans aged 60 and older hospitalized for nonpsychiatric medical or surgical treatment in 9 VA sites (UPBEAT, 814; usual care, 873). MEASURES: The Mental Health Inventory (MHI) anxiety and depression subscales, the Alcohol Use Disorder Identification Test (AUDIT) scores, RAND 36-Item Health Survey Short Form (SF-36), inpatient days and costs, ambulatory care clinic stops and costs, and mortality and readmission rates. RESULTS: Mental health and general health status scores improved equally from baseline to 12-month follow-up in both groups. UPBEAT increased outpatient costs by $1,171 (P <0.001) per patient, but lowered inpatient costs by $3,027 (P = 0.017), for an overall savings of $1,856 (P = 0.156). Inpatient savings were attributable to fewer bed days of care (3.30 days; P = 0.016) rather than fewer admissions. Patients with 1 or more pre-enrollment and postenrollment hospitalizations had the greatest overall savings ($6,015; P = 0.069). CONCLUSIONS: UPBEAT appears to accelerate the transition from inpatient to outpatient care for acute nonpsychiatric admissions. Care coordination and increased access to ambulatory psychiatric services produces similar improvement in mental health and general health status as usual care.

Aged↗
PubMed2001

Emotional and behavioral symptoms in children with acute leukemia.

BACKGROUND AND OBJECTIVES: The diagnosis of leukemia is probably one of the most severe stressors that children can experience and may be associated with emotional and behavioral symptoms indicating comorbidity with mental health disorders. This study aims to evaluate the presence of emotional and behavioral symptoms in children with acute leukemia exposed to chemotherapy from outpatient services at two university hospitals in Brazil. DESIGN AND METHODS: In this cross-sectional study, emotional and behavioral symptoms were assessed using the Children Behavior Checklist (CBCL) in three groups of children aged 5-14 years: a) children with acute leukemia (n = 21); b) children with blood dyscrasias (n = 21); c) children evaluated or treated in a pediatric outpatient service (n = 33). RESULTS: Children with blood dyscrasias had significantly few symptoms of externalization (delinquent and aggressive behavior) than pediatric controls (p< 0.05). Children with leukemia did not differ from the two other groups regarding symptoms of externalization. No significant difference on the scores of the CBCL internalization dimension (anxiety, depression, somatic symptoms and withdrawn) was found among the three groups. INTERPRETATION AND CONCLUSIONS: These findings seem to indicate that children with acute leukemia do not have more emotional or behavioral symptoms than children with benign hematologic or physical diseases suggesting that comorbidity with mental disorders is not higher in children with acute leukemia than in children in the other two groups.

Acute Disease↗
PubMed1998

Anticoagulation Clinic in the VA Pittsburgh Healthcare System.

This article describes the Anticoagulation Clinic (ACC) within the Veterans Administration Healthcare System. The clinic has been in operation for 10 years and has increased patient visits by 550 percent over this time period. Unlike many ACCs, inpatient anticoagulation management services have lagged behind outpatient services. The typical patient is an older white male who is prescribed warfarin for a cardiac condition (atrial fibrillation, mechanical heart valve replacement, congestive heart failure/cardiomyopathy). The VA system provides prescriptive authority and offers much latitude for patient management by ACC pharmacists. A comprehensive credentialing process has been developed, and quality improvement monitors show warfarin-related complications are comparable to other clinics and are less than routine medical care. In general, patients are satisfied with the care they receive and are comfortable with pharmacists monitoring and adjusting their warfarin therapy.

Anticoagulants↗
PubMed1996

Comparison of polymerase chain reaction and microbiological culture for detection of salmonellae in equine feces and environmental samples.

OBJECTIVE: To compare the sensitivity of polymerase chain reaction (PCR) with microbiological culture for detecting salmonellae in equine fecal samples and equine environmental swab specimens. DESIGN: Samples and specimens were tested by PCR and microbiological culture. SAMPLE POPULATION: A fecal sample from each of 152 horses admitted consecutively to the clinic for evaluation by the outpatient service, 282 fecal samples from 110 hospitalized horses that had been submitted to the clinical microbiology laboratory, and 313 environmental swab specimens were examined. PROCEDURE: Each sample and specimen in the study was tested, using PCR and microbiological culture. Results of PCR and culture were compared. RESULTS: Significantly (P < 0.001) more fecal samples were positive by PCR than by microbiological culture. 26 of 152 (17.1%) fecal samples collected from horses admitted by the outpatient service were positive by PCR and none was positive by culture. 71 of 110 hospitalized horses were identified as positive by PCR, compared with 11 horses identified as positive by culture. All culture-positive horses were positive by PCR. Of the 11 culture-positive horses, 10 (90.9%) were identified as PCR positive after testing of the first sample submitted, compared with 7 (63.6%) by culture. All PCR-positive horses were detected after a total of 3 samples/horse were submitted, whereas as many as 5 samples/horse was required to identify all culture-positive horses. 8 of 313 environmental specimens were positive by PCR, and none was positive by culture. CONCLUSION: The PCR method reported here was more sensitive, more rapid, and required submission of fewer samples or specimens than did microbiological culture for detecting salmonellae.

Animals↗
PubMed1975

Philadelphia's community based drug abuse program: broader medical and social concepts.

The rehabilitation of drug dependent people has undergone drastic changes since first attempts were made to curb the abuse of illegal drugs. The isolated law-enforcement model proved to be of no use in this area. So, too, the medical model, the psychological model and the public health model proved disappointingly low in their results. During the last ten years, a so-called "metabolic replacement model" has had its upsurge, creating a controversy still under discussion. The Drug Abuse Rehabilitation Programs of the West Philadelphia Community Mental Health Consortium, Inc. have been in the forefront with its treatment models. Established in 1968 as a purely methadone maintenance program, it has evolved into becoming a model, applying community mental health principles. This paper will explore this model further, describing the mechanics of its changes. From a municipal hospital-based methadone dispensing station, the program has developed into a multi-modality project. Three decentralized drug-free outpatient services are located in the midst of the community where the drug abuse problem is more accute. Outreach is emphasized and case-funding is applied. A possibly unique river-front motel was just acquired for the development of a community-based treatment modality. The 94 rooms were converted into a first-floor alcoholism program which also has a "highway safety program" and an intermediate care facility for alcoholics. The second floor of this facility contains outpatient services for the treatment of drug addicts, including a methadone maintenance program, counselling, family therapy and group therapy. The place where most of the emphasis has been placed is the Work Rehabilitation Center (a novel approach whereby patients will spend up to six hours in "partial hospitalization"). Clients will be tested for vocational aptitude and four workshops will be developed on the premises - carpentry, automotive, electricity and clerical. A huge cafeteria with a semi-automatic kitchen will allow further training in cooking and kitchen aids. The third floor of this renovated motel will include highly sophisticated clinical research area where computer utilization is already giving us very meaningful data. Clinical research is rapidly developing, and new drugs for the rehabilitation of drug addicts will be used. Further comments on the usefulness of methadone as a tool will be included in this paper and general comments as to the outcome of treatment further explored.

Alcoholism↗
PubMed1975

Triage abilities of nurse practitioner vs pediatrician.

The ability of ediatric nurse practitioners (PNPs) to perform triage functions for ill children in a busy pediatric outpatient service was compared to that of a group of pediatricians. One hundred thirteen children were seen separately on arrival by a PNP and by a pediatrician. The PNPs' evaluations agreed with the pediatricians' 84% of the time. Only two significant differences were shown: PNPs were more diligent in recording patient problems, while pediatricians were better able to anticipate the need for roentgenograms and laboratory studies. The results indicate that valuable physician time may be conserved by using the PNP to perform triage in large pediatric outpatient services.

Ambulatory Care↗
PubMedDate not supplied

[Between men and women, who uses up more health resources?].

Based on the 1999 data by the Lombard Information Department on Health, this study shows health consumption levels among resident people (hospitalisations, outpatient services, state-supported drugs), as divided by age and gender. The survey is aimed at producing significant figures about such variables as gender and age as determining factors. Given an age-associated mortality, health consumption has shown to be high in the first year of life, with a significant increase between 45-50 and 75-80, and a subsequent settlement or reduction. Excepting women in their fertile age, men account for greater health consumption in terms of hospitalisations and pharmaceuticals, whereas women do so in terms of outpatient services. As regards financial factors, mens services are generally more costly than womens.

English Abstract↗
PubMed1997

Consumer satisfaction with CMHC services.

To examine the relationship between consumer satisfaction with community mental health clinic (CMHC) services and patterns of outpatient service use, we conducted a survey of 210 schizophrenics in Mississippi, the majority of whom were African American. Subjects with lowest CMHC satisfaction were those who did not identify the CMHC as their primary source of outpatient mental health care. They were more likely to be white, single, and to either receive no outpatient mental health care (46%) or to seek care from sources other than the CMHC (54%), many of which might provide substandard care, such as family doctors, ministers, folk healers, or hospital emergency rooms. Among those who identified the CMHC as their primary source of mental health care, we found little evidence that satisfaction was associated with type, variety, or frequency of services. Even though clinics offered similar services, there were differences in consumer satisfaction ratings by clinics, suggesting that qualities of the clinic itself may influence consumer satisfaction.

Adolescent↗
PubMedDate not supplied

Long-term outcome after discharge from a stroke rehabilitation unit.

The evidence is compelling that stroke units are effective when compared to management of patients on general medical wards. However, the evidence remains equivocal that better outcome is sustained in the longer term. This paper reports an investigation of cognitive and emotional outcome, environmental consequences, social activities, and physical outcome in 57 consecutive one-year survivors of a stroke discharged from a stroke and neurological rehabilitation unit. Satisfaction with inpatient and outpatient services was also investigated. Results were compared with previously reported studies of long-term outcome after stroke. Mean Barthel activities of daily living score at one year or more post-stroke was 16.8. Arm function was impaired in 43% of the participants in the study. Nearly half had cognitive and emotional problems, 19% communication problems, and 25% problems with access both inside and outside their house. All but four of the one-year survivors were less active after their stroke than before. More than 40% were dissatisfied with at least one aspect of inpatient and/or outpatient services. The long-term consequences of stroke in all areas investigated were considerable and in line with previous reports. Some suggestions for reducing these effects are made, including better information for patients about stroke and rehabilitation, improved access to psychology services, detailed assessment prior to hospital discharge of the patient's living environment and effective coordination with social services to improve access to their living environment.

Activities of Daily Living↗
PubMed1991

[Evaluation of working conditions of municipal employees engaged in manual labor].

The working conditions of municipal employees of Botucatu (State of S. Paulo, Brazil) are described with a view to identifying the most frequent and serious occupational risks. Office workers (clerks) were not included in this study. The morbidities registered in the municipal outpatient service (from July 17 through December 4, 1987) and in the occupational accident register for the period 1984-1987 were evaluated. The activities of the majority of the employees were found to be carried out manually with no technological assistance, likely to generate "occupational accidents" (OA) and related to inadequate (antiergonomic) positions. The coefficient of severity of the OA has increased so rapidly that in 1987 it was 1.85 times higher than in 1984. The analysis of the external sources and the nature of the lesions caused by the OA were closely related to the description of the activities and the risk factors observed. The most frequent ailments registered in the outpatient service were: arterial hypertension, lumbago, the common cold, chronic alcoholism, acute gastroenterecolitis and "personal difficulties". An occupational health program for the municipal workers in Botucatu is proposed.

Accidents, Occupational↗
PubMed1987

An outpatient geriatric psychiatry assessment and treatment service.

An outpatient evaluation and treatment program for cognitively impaired elderly and their families opened at the University of Washington in 1978. The multidisciplinary approach includes psychiatric, medical, psychological, social, and environmental assessments. The program has been well received by the public and has served as a model for similar programs elsewhere. An important finding from the clinic has been to demonstrate the high frequency of excess disability in patients with dementia of the Alzheimer's type.

Aged↗
PubMed1999

Geographic variations in utilization rates in Veterans Affairs hospitals and clinics.

BACKGROUND: In the United States, geographic variation in hospital use is common. It is uncertain whether there are similar geographic variations in the health care system of the Department of Veterans Affairs (VA), which differs from the private sector because it predominantly serves men with annual incomes below $20,000, has a central system of administration, and uses salaried physicians. Thus, it might be less likely to have geographic variations. METHODS: We used VA data bases to obtain information on patients treated for eight diseases (chronic obstructive pulmonary disease, pneumonia, congestive heart failure, angina, diabetes, chronic renal failure, bipolar disorder, and major depression). We analyzed their use of hospital and outpatient services by assessing the risk-adjusted numbers of hospital days (the average number of days a patient spent in the hospital per 12 months of follow-up, regardless of the number of hospital stays), hospital-discharge rates, and clinic-visit rates from 1991 through 1995 for the entire system and within the 22 geographically based health care networks. RESULTS: We found substantial geographic variation in hospital use for all eight cohorts of patients and all the years studied. Variations in the numbers of hospital days per person-year among the networks were greatest among patients with chronic obstructive pulmonary disease (ranging from a factor of 2.7 to a factor of 3.1) during a given year and smallest among patients with angina (ranging from a factor of 1.5 to a factor of 2.1). Levels of hospital use were highest in the Northeast and lowest in the West. The variation in the rates of clinic visits for principal medical care among the networks ranged from a factor of approximately 1.6 to a factor of 4.0; variations in the rates were greatest among patients with chronic renal failure and smallest among patients with chronic obstructive pulmonary disease. There was no clear geographic pattern in the rates of outpatient-clinic use. CONCLUSIONS: There are significant geographic variations in the use of hospital and outpatient services in the VA health care system. Because VA physicians are unable to increase their income by changing their patterns of practice, our findings suggest that their practice styles are similar to those of other physicians in their geographic regions.

Chronic Disease↗
PubMed1981

Plasma theophylline assay service for outpatients.

It is generally agreed that the bronchodilator response to theophylline can be directly related to plasma concentration and that the efficacy of theophylline therapy can be improved if plasma concentrations are monitored. However, it is not known whether this improvement is realised in routine clinical practice. In this study, theophylline plasma concentrations were measured in 359 outpatients attending a teaching hospital respiratory medicine clinic. In nearly three-quarters of these patients (73.2%), the plasma concentration of theophylline was below the recommended therapeutic range of 55-110 mumoles/liter (10-20 mg/liter). These results were made available to the medical staff at the patient consultation. One hundred and seventy-seven patients reattended for a second visit and their plasma concentrations remeasured. At this visit, 63.2% of plasma levels were below the therapeutic range of 55-110 mumoles/liter; the percentage of patients in this therapeutic range had risen from 25.6% at the first visit to 33.9% at the second. Concentrations in excess of 110 mumoles/liter were rare and accounted for only 1.1-2.8% of sample assayed. The increase in the percentage of patients whose plasma concentration was in the therapeutic range may have been due to a better patient compliance resulting from provision of the "on-line" plasma monitoring service. The data suggest that physicians are conservative in their use of theophylline and may be maintaining the patients at a therapeutic range of 28-55 mumoles/liter, particularly when the drug is given with other therapeutic agents such as the beta 2-adrenoceptor agonists.

Adolescent↗
PubMedDate not supplied

[Basic principles of community, continuous and cooperative management of patients with chronic rheumatic diseases in Germany].

The lecture presents foundations and results of the work of a commission of the German Rheumatological Association. Based on epidemiological data on the occurrence of selected rheumatic disorders, reference figures for both, in- and outpatient services are developed. There is need of at least one full-time rheumatologist for every 150,000 residents. The commission identifies various actual deficits in the care of rheumatic patients. The most important seems to be the insufficient number and unequal spatial distribution of practicing rheumatologists. Other deficits concern the imperfect integration of preventive, curative and rehabilitative services, of in- and outpatient care and of the work of primary and secondary physicians with various allied health professionals at the community level.

Combined Modality Therapy↗
PubMed1984

The application of a modified follow-up life table technique to the study of outpatient clinic services for sickle-cell patients.

A cohort of 60 matched pairs of sickle-cell anaemia (SS) patients from Ibadan, Nigeria and Oakland, California, were compared in a follow-up study. The null hypothesis tested was that there was no significant difference in the morbidity associated with sickle-cell anaemia among Ibadan SS patients receiving antimalarial prophylaxis and Oakland SS patients. Proportions of all clinic visits during which the patients had crises or infections associated with sickle cell anaemia (SSINF) were used as measures of morbidity. A modification of the follow-up life table was used for the analysis. Plots of PX and its confidence bands against frequency of clinic visits due to crises and SSINF were drawn. The Kruskal Wallis test was used to determine any significant differences in the probability of SS patients from either of the two centres visiting the clinic because of crises or SSINF. The results showed no significant differences in these probabilities.

Actuarial Analysis↗
PubMed1995

The incidence and prevalence of anorexia nervosa in three suburban health districts in south west London, U.K.

OBJECTIVE: To determine incidence and prevalence of anorexia nervosa in a defined geographical area of south west London, UK, total population 519,900. METHOD: Hospital and community health workers in the defined area were contacted initially by letter asking them to identify all cases (new or existing) of anorexia nervosa known to them in the period July 1991-June 1992, using DSM-III-R criteria. A semistructured interview was conducted with the respondents to confirm the diagnosis. The large database record of the senior authors' specialist anorexia nervosa service, including inpatient and outpatient service records, was concurrently screened for cases living in the defined area. RESULTS: The prevalence of anorexia nervosa was found by this method to be 20.2 cases per 100,000 population (0.02% total population). Prevalence in females aged 15-29 years was 115.4 cases per 100,000 (0.1% of young females). Similarly, the annual incidence of anorexia nervosa was found to be 2.7 cases per 100,000 total population. In females aged 15-29 years the incidence was 19.2 cases per 100,000. DISCUSSION: Such prevalence and incidence figures are probably significant underestimates since the disorder can often defy detection or correct diagnosis and, with our own methodology, some identified cases may not have been reported to the study. However, these results can be used as a start for resource planning and service development.

Adolescent↗