Disparities in eye clinic patient encounters among patients requiring language interpreter services.

BACKGROUND: Communication barriers are a major cause of health disparities for patients with limited English proficiency (LEP). Medical interpreters play an important role in bridging this gap, however the impact of interpreters on outpatient eye center visits has not been studied. We aimed to evaluate the differences in length of eyecare visits between LEP patients self-identifying as requiring a medical interpreter and English speakers at a tertiary, safety-net hospital in the United States. METHODS: A retrospective review of patient encounter metrics collected by our electronic medical record was conducted for all visits between January 1, 2016 and March 13, 2020. Patient demographics, primary language spoken, self-identified need for interpreter and encounter characteristics including new patient status, patient time waiting for providers and time in room were collected. We compared visit times by patient's self-identification of need for an interpreter, with our main outcomes being time spent with ophthalmic technician, time spent with eyecare provider, and time waiting for eyecare provider. Interpreter services at our hospital are typically remote (via phone or video). RESULTS: A total of 87,157 patient encounters were analyzed, of which 26,443 (30.3%) involved LEP patients identifying as requiring an interpreter. After adjusting for patient age at visit, new patient status, physician status (attending or resident), and repeated patient visits, there was no difference in the length of time spent with technician or physician, or time spent waiting for physician, between English speakers and patients identifying as needing an interpreter. Patients who self-identified as requiring an interpreter were more likely to have an after-visit summary printed for them, and were also more likely to keep their appointment once it was made when compared to English speakers. CONCLUSIONS: Encounters with LEP patients who identify as requiring an interpreter were expected to be longer than those who did not indicate need for an interpreter, however we found that there was no difference in the length of time spent with technician or physician. This suggests providers may adjust their communication strategy during encounters with LEP patients identifying as needing an interpreter. Eyecare providers must be aware of this to prevent negative impacts on patient care. Equally important, healthcare systems should consider ways to prevent unreimbursed extra time from being a financial disincentive for seeing patients who request interpreter services.

Importance of access to epilepsy monitoring units during the COVID-19 pandemic: consensus statement of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology.

Restructuring of healthcare services during the COVID-19 pandemic has led to lockdown of epilepsy monitoring units (EMUs) in many hospitals. The ad-hoc taskforce of the International League Against Epilepsy (ILAE) and the International Federation of Clinical Neurophysiology (IFCN) highlights the detrimental effect of postponing video-EEG monitoring of patients with epilepsy and other paroxysmal events. The taskforce calls for action for continued functioning of EMUs during emergency situations, such as the COVID-19 pandemic. Long-term video-EEG monitoring is an essential diagnostic service. Access to video-EEG monitoring of the patients in the EMUs must be given high priority. Patients should be screened for COVID-19, before admission, according to the local regulations. Local policies for COVID-19 infection control should be adhered to during the video-EEG monitoring. In cases of differential diagnosis in which reduction of antiseizure medication is not required, home video-EEG monitoring should be considered as an alternative in selected patients.

Challenges in the provision of kidney care at the largest public nephrology center in Guatemala: a qualitative study with health professionals.

BACKGROUND: Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals' perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala. METHODS: Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions. RESULTS: Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services. CONCLUSIONS: Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.

Ambulatory care pharmacy practice in China: status and future efforts.

In recent years, as the era of deepening healthcare reform in China progresses, there is a gradual development of ambulatory care pharmacy practice. This commentary reviews the current state of ambulatory care pharmacy practice in China and discusses future efforts to advance the practice. Areas of focus include practice standardization, transitions of care, and reimbursements of ambulatory care pharmacy practice.

Retrospective assessment of the quality of diabetes care in a rural diabetes clinic in Western Kenya.

BACKGROUND: Sub-Saharan Africa continues to face the highest rate of mortality from diabetes in the world due to limited access to quality diabetes care. We assessed the quality of diabetes care in a rural diabetes clinic in western Kenya. METHODS: To provide a comprehensive assessment, a set of clinical outcomes, process, and structure metrics were evaluated to assess the quality of diabetes care provided in the outpatient clinic at Webuye District Hospital. The primary clinical outcome measures were the change in HbA1c and point of care blood glucose. In assessing process metrics, the primary measure was the percentage of patients who were lost to follow up. The structure metrics were assessed by evaluating different facets of the operation of the clinic and their accordance with the International Diabetes Federation (IDF) guidelines. RESULTS: A total of 524 patients were enrolled into the diabetes clinic during the predefined period of evaluation. The overall clinic population demonstrated a statistically significant reduction in HbA1c and point of care blood glucose at all time points of evaluation after baseline. Patients had a mean baseline HbA1C of 10.2% which decreased to 8.4% amongst the patients who remained in care after 18 months. In terms of process measures, 38 patients (7.3%) were characterized as being lost to follow up as they missed clinic visits for more than 6 months. Through the assessment of structural metrics, the clinic met at least the minimal standards of care for 14 out of the 19 domains recommended by the IDF. CONCLUSION: This analysis illustrates the gains made in various elements of diabetes care quality which can be used by other programs to guide diabetes care scale up across the region.

Improving accessibility for outpatients in specialist clinics: reducing long waiting times and waiting lists with a simple analytic approach.

BACKGROUND: Lack of resources is often cited as a reason for long waiting times and queues in health services. However, recent research indicates these problems are related to factors such as uncoordinated variation of demand and capacity, planning horizons, and lower capacity than the potential of actual resources. This study aimed to demonstrate that long waiting times and wait lists are not necessarily associated with increasing demand or changes in resources. We report how substantial reductions in waiting times/wait lists across a range of specialties was obtained by improvements of basic problems identified through value-stream mapping and unsophisticated analyses. METHODS: In-depth analyses of current operational processes by value-stream mapping were used to identify bottlenecks and sources of waste. Waiting parameters and measures of demand and resources were assessed monthly from 12 months before the intervention to 6 months after the intervention. The effect of the intervention on reducing waiting time and number of patients waiting were evaluated by a difference-in-differences analysis. RESULTS: Mean waiting time across all clinics was reduced from 162 + 69 days (range 74-312 days) at baseline to 52 + 10 days (range 41-74 days) 6 months after the intervention. The time needed to achieve a waiting time of 65 days varied from 4 to 21 months. The number of new patients waiting was reduced from 15,874 (range 369-2980) to 8922 (range 296-1650), and the number of delayed returning patients was reduced from 18,700 (310-3324) to 5993 (40-1337) (p < 0.01 for all). Improvement in waiting measures paralleled a significant increase in planning horizon. CONCLUSIONS: Significant improvements in accessibility for patients waiting for service may be achieved by applying unsophisticated methods and analyses and without increasing resources. Engagement of clinical management and involvement of front line personnel are important factors for improvement.

Measuring frailty in clinical practice: a comparison of physical frailty assessment methods in a geriatric out-patient clinic.

BACKGROUND: The objectives of this study were to determine: 1) the prevalence of frailty using Fried's phenotype method and the Short Performance Physical Battery (SPPB), 2) agreement between frailty assessment methods, 3) the feasibility of assessing frailty using Fried's phenotype method and the SPPB. METHODS: This cross-sectional study was conducted at a geriatric out-patient clinic in Hamilton, Canada. A research assistant conducted all frailty assessments. Patients were classified as non-frail, pre-frail or frail according to Fried's phenotype method and the SPPB. Agreement among methods is reported using the Cohen kappa statistic (standard error). Feasibility data included the percent of eligible participants agreeing to attempt the frailty assessments (criterion for feasibility: ≥90% of patients agreeing to the frailty assessment), equipment required, and safety considerations. A p-value of <0.05 is considered significant. RESULTS: A total of 110 participants (92%) and 109 participants (91%) agreed to attempt Fried's phenotype method and SPPB, respectively. No adverse events occurred during any assessments. According to Fried's phenotype method, the prevalence of frailty and pre-frailty was 35% and 56%, respectively, and according to the SPPB, the prevalence of frailty and pre-frailty was 50% and 35%, respectively. There was fair to moderate agreement between methods for determining which participants were frail (0.488 [0.082], p < 0.001) and pre-frail (0.272 [0.084], p = 0.002). CONCLUSIONS: Frailty and pre-frailty are common in this geriatric outpatient population, and there is fair to moderate agreement between Fried's phenotype method and the SPPB. Over 90% of the patients who were eligible for the study agreed to attempt the frailty assessments, demonstrating that according to our feasibility criteria, frailty can be assessed in this patient population. Assessing frailty may help clinicians identify high-risk patients and tailor interventions based on baseline frailty characteristics.

Utility of routine urinalysis and urine culture testing in an ambulatory urology clinic: a quality improvement initiative in a Veterans healthcare facility.

INTRODUCTION: Urinalysis (UA) and urine culture (UCx) are commonly performed tests in the urology clinic. Many of these urine studies are performed prior to the patient visit may not always be indicated, thus contributing to unintended consequences such as antibiotic use and costs without enhancing patient care. Our objective was to perform a quality improvement initiative aimed to assess the utility of routine UA/UCx. MATERIALS AND METHODS: The practice pattern at our site's Veteran Affairs (VA) urology clinic prior to 2014 was to obtain routine UA/UCx on most clinic visits prior to patient evaluation. Starting in 2014, we designed an intervention whereby our nurse practitioner triaged all new patient referrals and selectively ordered UA/UCx. We performed multivariable logistic regression to assess for predictors of obtaining UA or UCx. RESULTS: A total of 1308 patients were seen in January-March 2013 and 1456 in June-August 2014 and were included in this analysis. Fewer patients in 2014 received UA (59.8% versus 70.0%, p < 0.001) and UCx (49.6% versus 64.2%, p < 0.001). There was a decreased odds of obtaining UA in 2014 (OR 0.52, p < 0.001) as well as a decreased odds of obtaining UCx in 2014 (OR0.38, p < 0.001) on multivariable logistic regression. The results of UA/UCx only rarely resulted in change of management in either cohort (3%). Selective ordering resulted in an estimated cost savings of $4915.08/month in UCx costs alone. CONCLUSIONS: Our quality improvement initiatives reduced rates of UA/UCx testing when providers assess patients prior to ordering these tests. The implication of this initiative is significant cost savings for the healthcare system.

Reducing socioeconomic inequalities in COPD care in the hospital outpatient setting - A nationwide initiative.

OBJECTIVE: Socioeconomic differences in quality of care have been suggested to contribute to inequality in clinical prognosis of COPD. We examined socioeconomic differences in the quality of COPD outpatient care and the potential of a systematic quality improvement initiative in reducing potential socioeconomic differences. METHODS: A mandatory national quality improvement initiative has since 2008 monitored the quality of COPD care at all national pulmonary specialized outpatient clinics in Denmark using six evidence-based process performance measures. We followed patients aged ≥30 years with a first-ever outpatient contact for COPD during 2008-2012 (N = 23,741). Adjusted year-specific relative risks (RR) of fulfilling all relevant process performance measures was compared according to ethnicity, education, income, employment, and cohabitation using Poisson regression. RESULTS: Quality of care improved following the implementation of the clinical improvement initiative with 11% of COPD patients receiving optimal care in 2008 compared to 57% in 2012. Substantial socioeconomic differences were observed the first year: immigrants (RR 0.41, 95% CI 0.21-0.82), the unemployed (RR 0.37, 95% CI 0.18-0.74), disability pensioners (RR 0.63, 95% CI 0.46-0.87) and patients living alone (RR 0.80, 95% CI 0.60-0.97) were less likely to receive all relevant care processes, whereas those with highest education (RR 1.22, 95% CI 0.92-1.63) were more likely to receive these processes. These differences were eliminated during the study period. CONCLUSION: A systematic quality improvement initiative including regular audits, knowledge sharing, and detailed disease-specific recommendations for care improvement may increase the overall quality of care and considerably modify the substantial socioeconomic inequalities in COPD management.

Rapid-access cardiology services: can these reduce the burden of acute chest pain on Australian and New Zealand health services?

Chest pain is common and places a significant burden on hospital resources. Many patients with undifferentiated low- to intermediate-risk chest pain are admitted to hospital. Rapid-access cardiology (RAC) services are hospital co-located, cardiologist-led outpatient clinics that provide rapid assessment and immediate management but not long-term management. This service model is described as part of chest pain management and the National Service Framework for coronary heart disease in the United Kingdom (UK). We review the evidence on the effectiveness, safety and acceptability of RAC services. Our review finds that early assessment in RAC outpatient services of patients with suspected angina, without high-risk features suspicious of an acute coronary syndrome, is safe, can reduce hospitalisations, is cost effective and has good medical practitioner and patient acceptability. However, the literature is limited in that the evaluation of this model of care has been only in the UK. It is potentially suited to other settings and needs further evaluation in other settings to assess its utility.

Interventions unrelated to anticoagulation in a pharmacist-managed anticoagulation clinic.

PURPOSE: Results of a study to determine the number of interventions unrelated to anticoagulation made in a pharmacist-managed anticoagulation clinic are presented. METHODS: A retrospective, single-center cohort was conducted in a hospital-affiliated outpatient pharmacist-managed anticoagulation clinic. Patients were ≥18 years old and attended at least one face-to-face appointment between January 1, 2012, and November 30, 2013. The primary outcome was the number of interventions made outside of an anticoagulation clinic's primary purpose. Interventions were classified based on predetermined criteria. Results of selected interventions were determined along with the association between patient factors and having an intervention. Descriptive statistics and relative risk were used, when appropriate. RESULTS: A total of 268 patients were included, and 5846 pharmacist encounters were reviewed. Investigators identified 2222 interventions. Patients having >10 medications were 17% more likely to have an intervention compared with those having <5 medications. Patients attending at least two primary care visits within one year prior to their first appointment with a pharmacist were 12% more likely to have an intervention compared with those attending fewer than two appointments. CONCLUSION: Pharmacists in an anticoagulation clinic made a substantial number of interventions unrelated to anticoagulation therapy, with most clinic patients having at least one such intervention made on their behalf. The majority of these interventions were related to medication reconciliation. The total number of medications being taken and the number of physician visits were significantly associated with an intervention taking place.

Service quality of hospital outpatient departments: patients' perspective.

PURPOSE: Assessment of patient perceptions of health service quality as an important element in quality assessments has attracted much attention in recent years. The purpose of this paper is to assess the service quality of hospital outpatient departments affiliated to Shahid Beheshti University of Medical Sciences from the patients' perspective. DESIGN/METHODOLOGY/APPROACH: This cross-sectional study was conducted in 2014 in Tehran, Iran. The study samples included 500 patients who were selected by multi-stage random sampling from four hospitals. The data collection instrument was a questionnaire consisting of 50 items, and the validity and reliability of the questionnaire were confirmed. For data analysis, exploratory and confirmatory factor analysis, Friedman test, and descriptive statistics were used through LISREL 8.54 and SPSS 18 applications. FINDINGS: Eight significant factors were extracted for outpatient service quality, which explained about 67 per cent of the total variance. Physician consultation, information provided to the patient, and the physical environment of the clinic were the three determining factors of the quality of outpatient services. The highest and lowest perceptions were related to physician consultation and perceived waiting time dimension, respectively. The mean score of patients' perception of outpatient service quality was 3.89 (±0.60). About 59.5 per cent of patients assessed the quality of outpatient services as good, 38.2 per cent as moderate, and 2.3 per cent as poor. Practical implications - The instrument developed for this study is valid and reliable, and it can help hospital managers to identify the areas needing improvement and correction. ORIGINALITY/VALUE: According to the findings of this study, the majority of patients had a positive experience with outpatient departments of teaching hospitals, and the services provided in these centres were of adequate quality, based on patient assessments.

Patient satisfaction in Malaysia's busiest outpatient medical care.

This study aimed to explore factors associated with patient satisfaction of outpatient medical care in Malaysia. A cross-sectional exit survey was conducted among 340 outpatients aged between 13 and 80 years after successful clinical consultations and treatment acquirements using convenience sampling at the outpatient medical care of Tengku Ampuan Rahimah Hospital (HTAR), Malaysia, being the country's busiest medical outpatient facility. A survey that consisted of sociodemography, socioeconomic, and health characteristics and the validated Short-Form Patient Satisfaction Questionnaire (PSQ-18) scale were used. Patient satisfaction was the highest in terms of service factors or tangible priorities, particularly "technical quality" and "accessibility and convenience," but satisfaction was low in terms of service orientation of doctors, particularly the "time spent with doctor," "interpersonal manners," and "communication" during consultations. Gender, income level, and purpose of visit to the clinic were important correlates of patient satisfaction. Effort to improve service orientation among doctors through periodical professional development programs at hospital and national level is essential to boost the country's health service satisfaction.

Who is satisfied with general surgery clinic visits?

BACKGROUND: Patient satisfaction is an important patient outcome because it informs researchers and practitioners about patients' experience and identifies potential problems with their care. Patient satisfaction is typically studied through physician-patient interactions in primary care settings, and little is known about satisfaction with surgical consultations. METHODS: Participants responded to questionnaires before and after a surgical consultation. The study was conducted in a diverse outpatient clinic within a county hospital in Southern California. Participants were patients who came to the surgery clinic for their first appointment after referral from a primary care provider for a surgical consultation. RESULTS: Patients' ethnicity, educational attainment, and insurance status predict their satisfaction, and patients reliably differed in their satisfaction with care providers and with the hospital where they received their care. CONCLUSIONS: These findings add to knowledge about patient care by highlighting associations between patients' demographic characteristics and patients' differential satisfaction with particular entities within the context of surgical care.

Operational prototyping a tool for delivering value.

Operational prototyping is a disciplined approach to developing best practices that enable an organization to enhance value through improved quality of care and reduced costs. The aim of operational prototyping is to fine-tune performance to the level of best practices by considering every element involved in a care process, including the design of the facilities required to support the process. The broad goal of this approach is to be able to standardize and replicate the identified best practices in every location across a health system.

Assessment of alcohol histories obtained from patients with liver disease: opportunities to improve early intervention.

BACKGROUND: Alcohol is an important primary and comorbid cause of liver injury in patients referred for investigation and management of liver disease. Early assessment and documentation of alcohol consumption is therefore essential, and recommended in both general practice and hospital settings. AIMS: To determine the extent and accuracy of documentation of alcohol consumption in patients referred for evaluation of liver disease. METHODS: Patients were interviewed using a structured questionnaire. The medical records of all patients interviewed were reviewed to obtain information from the referral letter and the hepatology consultations. RESULTS: Eighty-three patients were surveyed. Only 14 referrals had an informative alcohol history, despite 27 patients admitting risky alcohol consumption at the initial hepatology consultation. Ninety per cent of initial consultations had an informative alcohol history documented, whereas only 56% of patients attending a follow-up appointment had informative documentation. Assessment of alcohol consumption was comparable between the hepatology consultation and the structured questionnaire, but four subjects had substantially different alcohol histories. Alcohol Use Disorders Identification Test identified all patients reporting harmful alcohol consumption on the questionnaire. CONCLUSIONS: Hazardous alcohol use is prevalent in subjects attending hepatology clinics, but informative alcohol histories, which are crucial to patient management, are rarely documented in referrals. Screening tools improve documentation and accuracy of alcohol histories, and their use by general practitioners and hospital clinicians would improve detection rates of hazardous drinking and allow earlier intervention. Systematic use of screening tools in hepatology clinics will provide opportunities for education and reinforce recommendations to reduce hazardous or harmful alcohol consumption.

Implementation of a pharmacist-managed heart failure medication titration clinic.

PURPOSE: The development, implementation, and initial results of a pharmacist-managed heart failure (HF) medication titration clinic are described. SUMMARY: In a quality-improvement initiative at a Veterans Affairs health care system, clinical pharmacists were incorporated into the hospital system's interprofessional outpatient HF clinic. In addition, a separate pharmacist-managed HF medication titration clinic was established, in which pharmacists were granted an advanced scope of practice and prescribing privileges, enabling them to initiate and adjust medication dosages under specific protocols jointly established by cardiology and pharmacy staff. Pharmacists involved in the titration clinic tracked patients' daily body weight, vital signs, and volume status using telephone-monitoring technology and via patient interviews. A retrospective chart review comparing achievement of target doses of angiotensin-converting enzyme inhibitor (ACEI), angiotensin-receptor blocker (ARB), and ß-blocker therapies in a group of patients (n = 28) whose dosage titrations were carried out by nurses or physicians prior to implementation of the pharmacist-managed HF medication titration clinic and a group of patients (n = 27) enrolled in the medication titration clinic during its first six months of operation indicated that target ACEI and ARB doses were achieved in a significantly higher percentage of pharmacist-managed titration clinic enrollees (52.9% versus 31%, p = 0.007). Patients enrolled in the pharmacist-managed HF medication titration clinic also had a significantly higher rate of attainment of optimal ß-blocker doses (49% versus 24.7%, p = 0.012). CONCLUSION: Implementation of a pharmacist-managed HF medication titration clinic increased the percentage of patients achieving optimal ACEI, ARB, and ß-blocker dosages.

[Satisfaction with an integrated care program for outpatients with schizophrenia or depression]. / Patientenzufriedenheit mit einem Programm der Integrierten Versorgung für die Indikationen Schizophrenie und Depression.

OBJECTIVE: To study out-patients' perception of an Integrated Care compliance program. METHODS: Survey of patients enrolled in the Integrated Care program "Münchner Modell" in Munich, Germany. RESULTS: N = 121 patients participated in the survey. Overall patients were very satisfied with the Integrated Care program. They reported improvements in several areas of life. CONCLUSION: The study highlights the aspects of routine patient care that still need to be improved and shows how these deficits can be addressed by Integrated Care programs.