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[Variation in the number of diagnostic analyses and tests in a hospital outpatient consulting clinic].

OBJECTIVE: To analyze the variation in the number of diagnostic test orders after physicians have been made aware of the need to order only the necessary tests for adequate patient diagnosis. MATERIAL AND METHODS: The study was done in a prospective manner in 3 successive steps during which 750 first-visit patients attending in an outpatient rheumatology clinic at a general hospital were analyzed. In the first step (baseline) data were collected without the physicians' knowledge. The results of the study were later presented at a grand round. In the second step (intervention) data were collected again, this time with the physicians' knowledge. A final data collection (control) was carried out 6 months later without physicians' knowledge again. RESULTS: In the baseline step 2.355 orders with a mean of 9.42 +/- 5.5 order/patient were done. In the intervention step, there was a reduction of 1,946 orders with a mean of 7.78 +/- 4.48 (p < 0.001). Six months later, in the control step, the number of orders was reduced to 1.806 with a mean of 7.22 +/- 5.16 orders/patient, with a 23.3% saving compared with the baseline step (p < 0.001). Also, significant differences were found in the number or orders among physicians at each step. Reduction was observed in every kind of diagnostic test. CONCLUSIONS: A considerable reduction of 23.3% in the number of analysis and diagnostic tests can be obtained if physicians are made aware of the need to order only the necessary tests for patients' diagnostic. This strategy may result in a significant containment in the growing health care cost we suffer nowadays.

Adult↗
PubMed1997

The effect of HLA-DRB1 disease susceptibility markers on the expression of RA.

The study was designed to examine the effect on clinical expression of rheumatoid arthritis (RA) of HLA alleles, particularly DR4 and DR1 that contain susceptibility sequences for RA in the third hypervariable region (HVR3) of HLA-DRB1. We studied 114 consecutive Australian patients with RA attending a hospital outpatient clinic. The effects on indices of disease severity and activity of HLA DR4 and DR1, the DRB1*04 subtypes, and the polymorphism in the RA susceptibility sequence (QRRAA or QKRAA) were examined. The patients were initially divided into 6 groups, DR4,4; DR4,1; DR1,1; DR4/X; DR1,X, and DRX/X, and then further subdivided according to the actual HVR3 susceptibility sequence. The high risk conferred by the HVR3 susceptibility sequence, present in 76%, was confirmed, but 24% of the patients with long-standing seropositive erosive RA lacked this sequence. Among these those with DR2 had early-onset severe disease, and those with DR3 had late-onset milder disease. Differences in expression correlated with polymorphisms in the susceptibility sequence, in that active RA was associated more with QRRAA than QKRAA. There was no correlation of any HLA allele with disease severity. Our finding that the presence of the HVR3 sequence confers susceptibility and also influences the clinical expression and tempo of progression of RA suggests a role in pathogenesis for antigen presentation, whether of an autoantigenic molecule or a persisting infection.

Adult↗
PubMed1991

[Results of population sociological survey regarding quality of outpatient clinics and hospital health care].

An analysis is made of the findings of sample survey of population views on the state of ambulatory and hospital care, the data on time spent to reach an out-patient department and to wait for an appointment to the district physician and also data on the degree of satisfaction with the performance of ambulatory and hospital institutions and medical specialists are provided, the reasons for dissatisfaction with their performance are given, the findings on providing timely care to the population by medical specialists, waiting lists for hospitalization, hospital care efficacy and reasons for refusal in hospitalization are provided.

Clinical Competence↗
PubMed1993

Prompting the clinical care of non-insulin dependent (type II) diabetic patients in an inner city area: one model of community care.

OBJECTIVE: To evaluate the effectiveness and acceptability of centrally organised prompting for coordinating community care of non-insulin dependent diabetic patients. DESIGN: Randomised single centre trial. Patients allocated to prompted care in the community or to continued attendance at hospital diabetic clinic (controls). Median follow up two years. SETTING: Two hospital outpatient clinics, 38 general practices, and 11 optometrists in the catchment area of a district general hospital in Islington. PATIENTS: 181 patients attending hospital outpatient clinics. NULL HYPOTHESIS: There is no difference in process of medical care measures and medical outcome between prompted community care and hospital clinic care. RESULTS: 14 hospital patients failed to receive a single review in the clinic as compared with three patients in the prompted group (chi 2 = 6.1, df = 1; p = 0.013). Follow up for retinal screening was better in prompted patients than in controls; two prompted patients defaulted as against 12 controls (chi 2 = 6.9, df = 1; p = 0.008). Three measures per patient yearly were more frequent in prompted patients: tests for albuminuria (median 3.0 v 2.3; p = 0.03), plasma glucose estimations (3.1 v 2.5; p = 0.003), and glycated haemoglobin estimations (2.4 v 0.9; p < 0.001). Continuity of care was better in the prompted group (3.2 v 2.2 reviews by each doctor seen; p < 0.001). The study ended with no significant differences between the groups in last recorded random plasma glucose concentration, glycated haemoglobin value, numbers admitted to hospital for a diabetes related reason, and number of deaths. Questionnaires revealed a high level of patient, general practitioner, and optometrist satisfaction. CONCLUSIONS: Six monthly prompting of non-insulin treated diabetic patients for care by inner city general practitioners and by optometrists is effective and acceptable.

Ambulatory Care↗
PubMed1964

TUBERCULOSIS: HOSPITALIZATION AND OUTPATIENT TREATMENT.

Initial hospitalization terminated by discharge upon medical advice to continue with chemotherapy on an outpatient basis represents the treatment of choice for most patients with active pulmonary tuberculosis. Any departure from this plan for any patient should be accepted only after careful consideration of all the circumstances. Patients with active pulmonary tuberculosis who are to receive outpatient chemotherapy without adequate initial hospitalization should be carefully selected by the local or provincial department of public health. Approval in writing should be required from the appropriate public health authority before antituberculosis chemotherapy is provided at public expense for any such patient, except possibly for a limited period while awaiting formal approval. In all instances, the clinic which dispenses the antituberculosis drugs should have the patient under supervision with recall for follow-up examinations as required. Prophylactic antituberculosis chemotherapy may be provided to certain groups of persons without hospitalization.

Ambulatory Care↗
PubMed1990

Prenatal care in Finland: from primary to tertiary health care?

Traditionally, the Finnish prenatal care system has been based on special maternity centers outside hospitals. In recent years, however, the use of hospital outpatient clinics has increased. The purpose of this study was to describe the use of the clinics and to see whether clinics serve as an addition or as an alternative to maternity centers. We used several different data sources (statistics, documents, interviews, questionnaires). The main source was data on visits for all women who gave birth in Helsinki in a five-week period in 1987. The content of care and means of care delivery differ between clinics and maternity centers. Clinics are technologically and provider-oriented without continuity of care. Clinics are not just referral centers for high-risk mothers; at least half of pregnant women visit them. Ultrasound screening is an important reason for use of the clinic. Background characteristics as well as the outcome of pregnancy were similar among women visiting a hospital clinic a maximum of one time (low users), two to three times, or four times or more (high users). Standardizing for the length of gestation, high users made fewer visits to maternity centers than did low users. Hospital clinic care now seems to replace care in maternity centers, and we found a weak trend toward a pluralistic prenatal care.

Adult↗
PubMed1999

What do internal medicine residents need to enhance their diabetes care?

OBJECTIVE: To identify areas that should be targeted for improvement in care, we examined internal medicine resident practice patterns and beliefs regarding diabetes in a large urban hospital outpatient clinic. RESEARCH DESIGN AND METHODS: Internal medicine residents were surveyed to assess the frequency at which they performed key diabetes quality of care indicators. Responses were compared with recorded performance derived from chart and laboratory database reviews. Resident attitudes about diabetes were determined using the Diabetes Attitude Survey for Practitioners. Finally, an eight-item scale was used to assess barriers to diabetes care. RESULTS: Both self-described and recorded performance of recommended diabetes services short of national recommendations. For yearly eye examinations and lipid screening, recorded performance levels were similar to trainees' reports. However, documented inquiries about patient self-monitoring of blood glucose, performance of foot examinations, and urine protein screening were lower than trainees' reports. Some 49% of the residents selected a target HbA1c of 6.6-7.5% as an attainable goal, yet half of the patients using oral agents or insulin had HbA1c values > 8.0%. No differences in self-described or recorded performance were found by year of training. Most residents did not perceive themselves to need additional training related to diabetes care, and residents were generally neutral about patient autonomy. Patient nonadherence and time constraints within the clinic were most often cited as barriers to care. CONCLUSIONS: The study identifies several areas that require improvement in resident care of diabetes in the ambulatory setting. Because experience during training contributes to future practice patterns, developing a program that teaches trainees how to implement diabetes practice guidelines and methods to achieve optimal glycemic control may be key to future improvements in the quality of diabetes care.

Adult↗
PubMed2005

Brief motivational intervention at a clinic visit reduces cocaine and heroin use.

BACKGROUND: Brief intervention is effective for alcohol misuse, but not adequately tested in the clinical setting with drug using patients. This study tested the impact of a single, structured encounter targeting cessation of drug use, conducted between peer educators and out-of-treatment cocaine and heroin users screened in the context of a routine medical visit. METHODS: A randomized, controlled trial was conducted in inner-city teaching hospital outpatient clinics with 3 and 6 months follow-up by blinded observers. Drug abstinence was documented by RIA hair testing. Analysis was limited to enrollees with drug-positive hair at baseline. RESULTS: Among 23,669 patients screened 5/98-11/00, 1232 (5%) were eligible, and 1175 enrolled. Enrollees (mean age 38 years) were 29% female, 62% non-hispanic black, 23% hispanic, 46% homeless. Among those with positive hair at entry, the follow-up rate was 82%. The intervention group was more likely to be abstinent than the control group for cocaine alone (22.3% versus 16.9%), heroin alone (40.2% versus 30.6%), and both drugs (17.4% versus 12.8%), with adjusted OR of 1.51-1.57. Cocaine levels in hair were reduced by 29% for the intervention group and only 4% for the control group. Reductions in opiate levels were similar (29% versus 25%). CONCLUSIONS: Brief motivational intervention may help patients achieve abstinence from heroin and cocaine.

Adult↗