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The psychiatric inpatient treatment of children and youth in general hospitals.

National attention has recently focused on the mental health needs and services of children and youth. The lack of outpatient services and their coordination has been noted, as well as the consequent press towards inpatient care. We describe the inpatient treatment of children and adolescents (ages 0-18) in short-term, non-Federal general hospitals in 1980. Nationally, 128,300 children were treated for mental disorders in general hospitals at an estimated cost of over $1.5 billion. Compared to adults, children were more likely to be treated in scatter beds (vs. specialty units); have a diagnosis of mental disorder (vs. alcohol/drug disorder); stay much longer; and pay with commercial insurance. Previous work focusing on psychiatric units of general hospitals identified less than 40% of the total episodes, a figure very similar to that for adults. The majority of psychiatric inpatient episodes for children and youth in the United States takes place in short-term general hospitals. Community psychologists need to be aware of national trends in inpatient care and be involved in the development and promulgation of alternative models of care.

Adolescent↗

Outpatient health care utilization of patients with inflammatory bowel disease.

On the basis of the normal life expectancy of inflammatory bowel disease patients, the early onset of their disease, and the variety of symptoms, inflammatory bowel disease patients were anticipated to be frequent users of outpatients services. This study assesses (1) the characteristics, (2) outpatient health care utilization, and (3) the degree of satisfaction with health care of inflammatory bowel disease patients compared to patients with other gastrointestinal disease. The study method was a secondary analysis of data collected on 395 patients attending the University of Calgary Gastroenterology Outpatient Clinic in 1988. Inflammatory bowel disease patients were significantly younger (P less than 0.001) and better educated (P less than 0.05) than other patients. During the past year inflammatory bowel disease patients consulted significantly more often with their gastroenterologist (P less than 0.001) and spent more time in hospital (P less than 0.05) than other patients. Inflammatory bowel disease patients also consulted more frequently with herbalists and naturopaths. Lastly, inflammatory bowel disease patients were as satisfied with the health care they received as other patients. These results provide information useful for health care planners as well as for those dealing directly with inflammatory bowel disease patients.

Adolescent↗

Latent human papillomavirus infection in pregnant women at term: a case-control study.

Cervicovaginal lavages from 752 pregnant women at term were investigated by polymerase chain reaction to evaluate human papillomavirus (HPV) infection prevalences and were compared with cervicovaginal samples from two series of nonpregnant subjects (504 healthy women attending a family planning service and 560 symptomatic patients attending a vaginitis outpatient service). The odds ratios (ORs) of HPV infection were computed by conditional logistic regression analysis on age-matched sets. In pregnant women, the overall risk of HPV infection was about the same as in nonpregnant healthy subjects (adjusted OR, 0.90; 95% confidence interval [CI], 0.51-1.58) and was 50% less than in patients with symptomatic vaginitis (adjusted OR, 0.48; 95% CI, 0.30-0.76). Moreover, the prevalence of oncogenic HPV types 16 or 18 (or both) was lower in pregnant women (P = .015 and P = .0018 respectively).

Adolescent↗

Inpatient and outpatient outcomes in Missouri's alcohol and drug treatment programs.

A comparison of the effectiveness of inpatient and outpatient services for alcohol and drug clients is presented. Controls for program completion and severity of substance use on entry to treatment are included. While inpatients do only as well as outpatients overall, inpatient services show significant advantage for particular classes of clients. Results, though preliminary, suggest that the recent call for a cutback in inpatient services is premature.

Alcoholism↗

[Epidemiological aspects of ciprofloxacin-resistant Escherichia coli at a general hospital].

The susceptibility to ciprofloxacin of 7288 Escherichia coli clinical isolates from 5667 patients was determined over a 4-year period (1995-1998). Information about the patients' age, sex, specimen type, date, origin and susceptibility to Escherichia coli isolates was studied, and the c2 test was used for statistical comparison. Overall, 1003 (17.70%) patients out of the 5667 included in the study presented ciprofloxacin resistance. The annual resistance observed over this 4-year period was not considered statistically significant. The resistant isolates were more frequent among men, in urine specimens and in outpatients, and increased with different age groups. The average age of patients with resistant isolates was 61.29 years (SD 21.56) and that of patients with susceptible isolates was 39.76 years (SD 27.41). A similar rate of resistance was observed among outpatients from health centers and those from hospital outpatient services. The higher resistance rates were found in outpatients from the urology department. The resistance to other fluoroquinolones remained the same and was not significant for norfloxacin; it increased starting from 1997 for pefloxacin at the expense of ciprofloxacin-sensitive isolates.

Adolescent↗

[Epidemiological aspects of ciprofloxacin-resistant Escherichia coli in a general hospital]

The susceptibility to ciprofloxacin of 7288 Escherichia coli clinical isolates from 5667 patients was determined over a 4-year period (1995-1998). Information about the patients' age, sex, specimen type, date, origin and susceptibility to Escherichia coli isolates was studied, and the c2 test was used for statistical comparison. Overall, 1003 (17.70%) patients out of the 5667 included in the study presented ciprofloxacin resistance. The annual resistance observed over this 4-year period was not considered statistically significant. The resistant isolates were more frequent among men, in urine specimens and in outpatients, and increased with different age groups. The average age of patients with resistant isolates was 61.29 years (SD 21.56) and that of pacients with susceptible isolates was 39.76 years (SD 27.41). A similar rate of resistance was observed among outpatients from health centers and those from hospital outpatient services. The higher resistance rates were found in outpatients from the urology department. The resistance to other fluoroquinolones remained the same and was not significant for norfloxacin; it increased starting from 1997 for pefloxacin at the expense of ciprofloxacin-sensitive isolates.

Journal Article↗

Achieving short-term Medicare savings through the expansion of the prospective payment system.

This article addresses the introduction of competition into the Medicare prospective payment system (PPS), the application of aa expanded PPS to ensure that Medicare is not paying more than the market price for comparable services, the expansion of the Medicare PPS to outpatient services, and the expansion of the Medicare PPS to physician fees for inpatient care.

Ambulatory Care↗

Margin alert: time to revisit your outpatient strategy.

An increasingly competitive market for outpatient services has made it necessary for acute care hospitals to reevaluate their outpatient, and inpatient, strategies. Many acute care hospitals are in a strong market position to command premium payment for their inpatient services. Under current market conditions, hospitals are in danger of pricing themselves out of the outpatient market. Hospitals can benefit from the increased focus of consumers and payers on quality and the rise of pay for performance by investing in service excellence.

Economic Competition↗

Developing and evaluating complementary therapy services: part 2. Examining the effects of treatment on health status.

OBJECTIVES: To investigate the effect on patient health status of an outpatient service providing acupuncture, osteopathy, and homeopathy. DESIGN: Pragmatic quasiexperimental design with waiting-list control group. SETTING: A district general hospital in the United Kingdom. SUBJECTS: All patients referred to the service during the study period. OUTCOME MEASURES: The Short Form 36-Item Health Status Survey (SF-36). RESULTS: With the exception of the Physical Functioning scale, statistical differences in scores were found between the treatment and control group on all SF-36 scales. Sensitivity analysis designed to deal with nonresponse supports the robustness of the results. CONCLUSION: This study provides evidence for the effectiveness of an outpatient acupuncture, osteopathy and homeopathy service in terms of benefits to patients' health status.

Acupuncture↗

Gender differences in the use of outpatient mental health services.

Current economic constraints necessitate careful planning and evaluation of mental health services. Gender differences in need and use of outpatient mental health services are synthesized based on current epidemiological research. Although overall prevalence rates of mental disorder are similar, women use more outpatient mental health services than do men. This disparity exists largely within the primary care sector. The study of social roles and behavior may help explain these gender differences. Implications for planning and organizing outpatient mental health services are discussed.

Canada↗

Implementing clinical pharmacy services in an outpatient oncology clinic.

The implementation of clinical pharmacy services in an outpatient oncology clinic is described. An oncologist hired by the department of internal medicine and the director of the department of pharmacy designed the program. Both departments agreed that the pharmacists should have central responsibility for the antineoplastic agents. Pharmacists for the program were selected from the existing staff. They were trained in an established i.v. therapy certification course offered by the hospital. The biweekly clinics are staffed by a team consisting of two pharmacists, three nurses, two faculty physicians, and a rotating resident physician. The pharmacists provide clinical and distributive services including patient monitoring and medication storage, delivery, preparation, administration, and disposal. A survey showed that the pharmacists were well accepted by the other members of the team. After a trial period, principles of break-even analysis and differential accounting were used to justify the costs of the program. This program will remain an integral part of this hospital's pharmaceutical services.

Antineoplastic Agents↗

Effects of fiscal retrenchment on public mental health services for the chronic mentally ill.

In reviewing the public mental health services of 11 California counties during a period of fiscal retrenchment, we found several common trends: a greater focus on the severely mentally disabled; an increase in utilization of hospital-based care, residential treatment, day treatment, and case management services; and a decrease in the capacity of traditional outpatient services. Although the severely mentally disabled are receiving a higher priority for service, the findings imply that these service systems continue to inadequately address the need for long-term maintenance and supportive services to this population.

California↗

The impact of realignment on utilization and cost of community-based mental health services in California.

Decentralization of California's public mental health system under program realignment has changed the utilization and cost of community-based mental health services. This study examined a sample of 75,951 users, representing 1.5 million adults who visited California's public mental health services during a 6-year period (FY 1988-1990 and FY 1992-1994). Regression analysis was performed to examine cost and utilization reduction over time, across regions, and across psychiatric diagnoses. Overall utilization and cost of community-based mental health services dropped significantly after the implementation of realignment. They were significantly lower for (a) 24-hour services in the urban industrialized Southern Region and (b) outpatient services in the agricultural Central Region of the state. Users diagnosed with mood disorders took a greater portion, but were associated with significantly less treatment and cost than other users in the post-realignment period. When local communities bear the financial risks and rewards, they find more efficient methods of delivering community-based mental health services.

Adult↗

Prospective cost allocations for the chronic schizophrenic patient.

Schizophrenia affects from 0.5 percent to 1.0 percent of the population and is often a chronic relapsing illness with high morbidity. Because it strikes young adults, the lifetime direct and indirect costs are considerable. One method of budgeting the costs of treatment is through a prospective method with the development of "risk-adjusted" capitation rates that take into account a patient's past use of services, perceived health status, and level of disability. Such a system may provide opportunities to improve the quality of mental health services by increasing service flexibility, particularly in the development and differentiation of outpatient services. The essence of the approach is to encourage early intervention by reducing financial barriers for patients, especially barriers to alternatives to expensive inpatient services. One method currently employed in Rochester, New York, which creates a capitation payment system for the chronically mentally ill, will be described. The implications of this system for public policy will be discussed as we struggle to treat and care for chronic schizophrenic patients in humane and compassionate ways.

Capitation Fee↗

Attenuation of racial differences in health service utilization patterns for previously uninsured children in the Delta.

CONTEXT: A school-based health insurance program for children of the working poor was conducted in 2 isolated, rural communities in the Lower Mississippi Delta region. The larger of the 2 communities had an array of locally available health care providers, whereas the smaller community did not. In response to this lack of available care, the project designed and delivered outreach programs, including transportation to providers. PURPOSE: The purpose of this paper is to examine the role of race, age, and gender in the relationships between the utilization of care and the impact of outreach programs. METHOD: General estimating equation models are used to examine the response of utilization variables to race, age, gender, and community. Four years of insurance claims data are analyzed. FINDINGS: Race is seen to be an important component of utilization. The majority of participants were African American; however, children receiving prescription services, emergency room care, routine physician visits, and hospital outpatient services were more likely to be white. Outreach programs in vision and dental services were found to eliminate racial differences and increase utilization. A relatively strong gender effect was found in prescription, wellness, vision, and dental services. CONCLUSIONS: Previous research has shown differences by race in utilization of care. Our findings show that targeted outreach programs can significantly diminish these differences. Findings also suggest that barriers to health care for poor rural children are closely linked to transportation and availability of providers, not merely to cost of care or insurance.

Black or African American↗

Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study.

OBJECTIVE: To estimate the prevalence of medically unexplained symptoms in patients who most frequently attend outpatient services. DESIGN: Retrospective cohort study over three years with review of case notes. SETTING: Secondary care services in the South Thames (West) NHS region. PARTICIPANTS: Outpatient attenders with new appointments in 1993. MAIN OUTCOME MEASURES: Number of outpatient appointments, and number of consultation episodes for medically unexplained conditions. RESULTS: Medical records of 361 of 400 sampled frequent attenders were examined, and 971 consultation episodes were recorded. Ninety seven (27%) had one or more consultation episodes in which the condition was medically unexplained; 208 (21%) of the 971 consultation episodes were medically unexplained. Abdominal pain, chest pain, headache, and back pain were commonly found to be medically unexplained. CONCLUSIONS: Medically unexplained symptoms present in most hospital specialties and account for a considerable proportion of consultations by frequent attenders in secondary care.

Abdominal Pain↗

Developing effective services for patients with personality disorders.

OBJECTIVE: This review focused on empirical research that addressed the effectiveness of service models for the care of patients with personality disorders. METHOD: Services discussed included those delivering acute care, such as crisis and emergency services and acute psychiatric hospitalization; continuing care, such as outpatient services, day hospital treatment, and assertive community treatment programs; and other community programming, such as integrated treatment for comorbid substance abuse and psychoeducational interventions for families of patients with personality disorders. The review focused on studies that included patients with personality disorders, and it measured outcomes relevant to patients with personality disorders. Evidence from randomized controlled trials was highlighted. RESULTS: Few systematic studies of acute services were available. Community programming can decrease the risk of suicide attempts and reliance on inpatient admissions. Services must develop methods of ensuring compliance with treatment. Assertive community treatment for Axis II patients should be developed, implemented, and tested. Comprehensive programming for patients with personality disorders must include integrated treatment for substance abuse and family psychoeducational programs. CONCLUSION: Promising new models of care for patients with personality disorders are ready for testing and wider application.

Aftercare↗

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↗