Does Systemic Lupus Erythematosus Care Provided in a Lupus Clinic Result in Higher Quality of Care Than That Provided in a General Rheumatology Clinic?

OBJECTIVE: To compare the quality of care received by patients with systemic lupus erythematosus (SLE) in 2 settings within the academic institution (a dedicated lupus clinic and a general rheumatology clinic) using validated SLE quality measures. METHODS: One hundred fifty consenting, consecutive SLE patients receiving longitudinal care at the Rush University general rheumatology clinic (n = 73) or the subspecialty lupus clinic (n = 77) were recruited. An updated quality measure survey and retrospective medical chart review were used to evaluate each quality measure (n = 20). The overall and individual quality measure performance was calculated and compared between the 2 groups. Data on the number of SLE patients seen by each rheumatologist were collected to assess the relationship between SLE patient volume and quality measures. RESULTS: Overall quality measure performance was significantly better in SLE patients receiving care at the lupus clinic (85.8% versus 70.2% of patients receiving care at the general rheumatology clinic; P = 0.001). Differences between the 2 groups were observed for sunscreen counseling (98.7% and 83.6%, respectively; P = 0.001), antiphospholipid antibody testing (71.4% and 37%, respectively; P < 0.001), pneumococcal vaccination (84.8% and 48.8%, respectively; P < 0.001), bone mineral density testing (94.2% and 54.5%, respectively; P < 0.001), drug counseling (92.2% and 80.8%, respectively; P = 0.04), use of a steroid-sparing agent (100% and 82%, respectively; P < 0.007), use of an angiotensin-converting enzyme inhibitor (94.4% and 58.3%, respectively; P = 0.03), and cardiovascular disease risk assessment (40.3% and 15.1%, respectively; P = 0.01). There was a moderate correlation between physician volume and quality measure performance (ρ = 0.48, P < 0.001). CONCLUSION: Compared with the general rheumatology clinic, the dedicated lupus clinic had better quality measure performance in this cross-sectional single-center study. In our health care system, we also observed indicators suggesting that rheumatologists with a higher volume of SLE patients provide higher quality of care.

Snapshot of an Outpatient Supportive Care Center at a Comprehensive Cancer Center.

BACKGROUND: Integration of palliative care (PC) in oncology have been found to improve symptom distress, quality of life, and survival in patients with advanced cancer. Early integration is most appropriate in the outpatient setting. However, most PC services in the United States do not have an outpatient component. Our study aims to provide a snapshot of the type of patients and families who are referred to this novel setting for the delivery of early PC. CONCLUSION: Traditionally, PC has been delivered predominantly to patients with advanced disease and to aid in transition to end of life. In recent years, outpatient centers have dramatically changed the nature of PC work as in our snapshot, which shows that in addition to patients regarded as more traditional patients, such as those transitioning to end of life, there are now patients who come in very soon after arrival to a cancer center requiring specialized care to address a variety of symptom and educational needs, thus requiring adaptation of structure and processes to allow access for frequent follow-ups, counseling, and flexibility for walk-in visits. Our findings suggest that Supportive Care Clinic needs to practice in a very different way, which requires certain skills and assessment tools that are not conventionally present in traditional oncology clinic settings. More research is needed to identify the type of patients who would benefit most from a PC referral.

Vitamin D deficiency in adult fracture patients: prevalence and risk factors.

PURPOSE: Although vitamin D levels are not routinely monitored in outpatient fracture patients, identification of fracture patients with a deficient vitamin D status may be clinically relevant because of the potential role of vitamin D in fracture healing. This study aimed to determine the prevalence of and risk factors for vitamin D deficiency in non-operatively treated adult fracture patients. PATIENTS AND METHODS: Vitamin D levels were determined in a cross-sectional study of adult patients, who were treated non-operatively for a fracture of the upper or lower extremity in the outpatient clinic of a level 1 trauma center, during one calendar year. Potential risk factors for (severe) vitamin D deficiency were analyzed using multivariable logistic regression analysis. RESULTS: A total of 208 men and 319 women with a mean age of 49.7 years (SD 19.9) were included. In this population, 71 % had a serum calcidiol <75 nmol/L, 40 % were vitamin D deficient (serum calcidiol <50 nmol/L) and 11 % were severely vitamin D deficient (serum calcidiol <25 nmol/L). Smoking and season (winter and spring) were independent risk factors for vitamin D deficiency. An increasing age, a non-Caucasian skin type, winter and smoking were identified as independent risk factors for severe vitamin D deficiency. The use of vitamin D, alcohol consumption and higher average daily sun exposure were independent protective factors against (severe) vitamin D deficiency. CONCLUSION: Given the potential role of vitamin D in fracture healing, clinicians treating adult fracture patients should be aware of the frequent presence of vitamin D deficiency during the winter, especially in smoking and non-Caucasian patients. Research on the effect of vitamin D deficiency or supplementation on fracture healing is needed, before suggesting routine monitoring or supplementation.

[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.

Maximizing medication therapy management services through a referral initiative.

PURPOSE: The implementation and effects of an initiative to refer patients to receive medication therapy management (MTM) services after hospital discharge are described. METHODS: A check box to order an MTM appointment was added to the discharge medication order form printed for hospitalized patients in an integrated health system. Hospitalists were informed about MTM services and encouraged to refer hospitalized patients to the service who were at risk for adverse drug events or medication nonadherence. A retrospective case series review was conducted to evaluate documented MTM encounters, comparing the number of patients seen at the MTM practice for hospital follow-up during the four months before and after the initiative's implementation. Secondary endpoints included revenue generated by MTM encounters and the percentage of patients with documented drug therapy problems due to medication nonadherence. RESULTS: A total of 313 encounters were included in the analysis (142 preimplementation and 171 postimplementation). The percentage of MTM hospital follow-up encounters significantly increased from the preimplementation period to the post-implementation period, from 30.28% (n = 43) to 63.74% (n = 109) (p < 0.001). After the referral initiative was implemented, MTM hospital follow-up encounters were more likely to reveal medication nonadherence, compared with regular office visits (odds ratio, 2.1; 95% confidence interval, 1.01-4.34; p = 0.039). CONCLUSION: The implementation of an initiative to refer hospitalized patients to an MTM service in an integrated health system increased the percentage of recently discharged patients seen in an MTM practice; patients seen postimplementation were more likely to be nonadherent to their medication regimen.

Guideline adherence and macrolides reduced mortality in outpatients with pneumonia.

BACKGROUND: For outpatients with pneumonia, guidelines recommend empiric antibiotics and some suggest macrolides are preferred agents. We hypothesized that both guideline-concordant antibiotics and macrolides would be associated with reduced mortality. METHODS: All outpatients with pneumonia assessed at 7 Emergency Departments in Edmonton, Alberta, Canada were enrolled in a population-based registry that included clinical-radiographic data, Pneumonia Severity Index (PSI) and treatments. Guideline-concordant regimens included macrolides and respiratory fluoroquinolones; other regimens were "discordant". Main outcome was 30-day all-cause mortality. RESULTS: The study included 2973 outpatients; mean age 51 years, 47% female, most had mild pneumonia (73% PSI Class I-II). Over 30-days, 38 (1%) patients died, 228 (8%) were hospitalized, and 253 (9%) reached the endpoint of death or hospitalization. Most (2845 [96%]) patients received guideline-concordant antibiotics. Compared to patients receiving discordant antibiotics, those receiving guideline-concordant antibiotics were less likely to die within 30-days (8 [6%] versus 30 [1%], adjusted OR 0.23, 95% CI 0.09-0.59, p = 0.002). Within the guideline-concordant subgroup, compared to the 947 (33%) patients treated with fluoroquinolones, those receiving macrolides [1847 (64%)] were less likely to die (25 [3%] versus 4 [0.2%], adjusted OR 0.28, 95% CI 0.09-0.86, p = 0.03). CONCLUSIONS: In outpatients with pneumonia, treatment with guideline-concordant antibiotics and macrolides were both associated with mortality reduction.

Recruitment activities for a nationwide, population-based, group-randomized trial: the VA MI-Plus study.

BACKGROUND: The Veterans Health Administration (VHA) oversees the largest integrated healthcare system in the United States. The feasibility of a large-scale, nationwide, group-randomized implementation trial of VHA outpatient practices has not been reported. We describe the recruitment and enrollment of such a trial testing a clinician-directed, Internet-delivered intervention for improving the care of postmyocardial infarction patients with multiple comorbidities. METHODS: With a recruitment goal of 200 eligible community-based outpatient clinics, parent VHA facilities (medical centers) were recruited because they oversee their affiliated clinics and the research conducted there. Eligible facilities had at least four VHA-owned and -operated primary care clinics, an affiliated Institutional Review Board (IRB), and no ongoing, potentially overlapping, quality-improvement study. Between December 2003 and December 2005, in two consecutive phases, we used initial and then intensified recruitment strategies. RESULTS: Overall, 48 of 66 (73%) eligible facilities were recruited. Of the 219 clinics and 957 clinicians associated with the 48 facilities, 168 (78%) clinics and 401 (42%) clinicians participated. The median time from initial facility contact to clinic enrollment was 222 days, which decreased by over one-third from the first to the second recruitment phase (medians: 323 and 195 days, respectively; p < .001), when more structured recruitment with physician recruiters was implemented and a dedicated IRB manager was added to the coordinating center staff. CONCLUSIONS: Large group-randomized trials benefit from having dedicated physician investigators and IRB personnel involved in recruitment. A large-scale, nationally representative, group-randomized trial of community-based clinics is feasible within the VHA or a similar national healthcare system.

Models of antenatal care and obstetric outcomes in Sydney South West.

OBJECTIVES: To assess obstetric outcomes of different models of antenatal care. METHODS: The study was historical cohort analysis of population birth data of 67,675 singleton births delivered in all public hospitals in Sydney South-west. Maternal and neonatal outcomes were compared for different models of antenatal care received. The care was provided within the hospitals in doctor's clinic, midwives' clinic, birth centre, or by a team of midwives in the caseload midwifery. In the non-hospital settings, the care was provided by private obstetricians or by the general practitioner (GP) as part of the GP Shared Care program. The data for those women who received no antenatal care were also analysed. RESULTS: This study provided information that the obstetric outcomes were very similar regardless of whether a woman received her antenatal care in the midwives' clinic, the birth centre, under the GP Shared Care program or in the doctor's clinic in Sydney South-west hospitals. CONCLUSIONS: This study provides evidence for the view that different models of maternity care can be provided with good outcomes.

Outcome related to impact on daily living: preliminary validation of the ORIDL instrument.

BACKGROUND: The challenge of finding practical, patient-rated outcome measures is a key issue in the evaluation of health care systems and interventions. The ORIDL (Outcome in Relation to Impact on Daily Living) instrument (formerly referred to as the Glasgow Homoeopathic Hospital Outcomes Scale or GHHOS) has been developed to measure patient's views of the outcome of their care by asking about change, and relating this to impact on daily life. The aim of the present paper is to describe the background and potential uses of the ORIDL, and to report on its preliminary validation in a series of three studies in secondary and primary care. METHODS: In the first study, 105 patients attending the Glasgow Homoeopathic Hospital (GHH) were followed-up at 12 months and changes in health status were measured by the EuroQol (EQOL) and the ORIDL. In the second study, 187 new patients at the GHH were followed-up at 3, 12, and 33 months, using the ORIDL, the Short Form 12 (SF-12), and the Measure Yourself Medical Outcome Profile (MYMOP). In study three, 323 patients in primary care were followed for 1 month post-consultation using the ORIDL and MYMOP. In all 3 studies the Patient Enablement Instrument (PEI) was also used as an outcome measure. RESULTS: Study 1 showed substantial improvements in main complaint and well-being over 12 months using the ORIDL, with two-thirds of patients reporting improvements in daily living. These improvements were not significantly correlated with changes in serial measures of the EQOL between baseline and 12 months, but were correlated with the EQOL transitions measure. Study 2 showed step-wise improvements in ORIDL scores between 3 and 33 months, which were only weakly associated with similar changes in SF-12 scores. However, MYMOP change scores correlated well with ORIDL scores at all time points. Study 3 showed similar high correlations between ORIDL scores and MYMOP scores. In all 3 studies, ORIDL scores were also significantly correlated with PEI-outcome scores. CONCLUSION: There is significant agreement between patient outcomes assessed by the ORIDL and the EQOL transition scale, the MYMOP, and the PEI-outcome instrument, suggesting that the ORIDL may be a valid and sensitive tool for measuring change in relation to impact on life.

[Current legal initiative to integrated care - effects of outpatient care in hospitals]. / Aktuelle gesetzgeberische Initiativen zur Integrierten Versorgung - Auswirkungen auf die ambulante Versorgung am Krankenhaus.

The strict separation of the out-patient and hospital-based health care delivery sectors in Germany leads to deficits in effectiveness and efficiency. Newly introduced legal initiatives to overcome this separation, namely "Ambulantes Operieren" (section 115 b SGB V), "Ambulante Behandlung durch Krankenhäuser" and Disease Management Programs (sections 116a-b SGB V) are described in detail in this article. Their impact on hospital-based health provision for out-patients is discussed. The aim of a better integration of different sectors with a better quality and a more efficient use of resources seems to be the target of these initiatives.

Setting up QI programs for pediatric specialty clinics.

This article reviews how to create a quality improvement (QI) reporting system for a multiple subspecialty pediatric clinic that is part of an acute pediatric facility in a major metropolitan area. The history of the facility, the needs of the organization, and areas that could be developed to create a comprehensive QI program are described. Examples of the data and format of QI studies are presented as well as future plans for continuing program development.

Reduced low birth weight for teenagers receiving prenatal care at a school-based health center: effect of access and comprehensive care.

PURPOSE: To examine and compare access to care, comprehensiveness of care, and birth outcomes for teenagers receiving prenatal care in comprehensive adolescent pregnancy programs (CAPPS) in two different settings: school-based vs. hospital-based. METHODS: Retrospective sohort study using existing data sources: medical records and birth certificates. Using school rosters and hospital clinic databases, we identified pregnant adolescents < or =18 years old who delivered a baby between July 1, 1995 and August 30, 1997 and who received prenatal care in a school-based CAPP (SB-CAPP) or hospital-based CAPP (HB-CAPP). Process of care measures (prenatal care adequacy and comprehensive care) and outcomes (low birth weight) were examined by site of care. Logistic regression models were computed to predict the odds of low birth weight by site of prenatal care, adjusting for prenatal care adequacy, comprehensive care, and possible confounders including baseline maternal characteristics. RESULTS: Three-hundred-ninety eligible teens were identified. Mean age was 15.9 years, 93% were African-American, 84% in school, 13% had a prior birth, and 11% were cigarette smokers. Teens receiving care in the SB-CAPP were significantly younger and more likely to be in school than those in the HB-CAPP. Overall, the two groups had similar low rates of prenatal care adequacy, but compared with teens in the SB-CAPP, those in the HB-CAPP were 1.5 times less likely to receive comprehensive care. Logistic regression analyses adjusting for baseline maternal differences showed that HB-CAPP teens were more than three times as likely to deliver a low birth weight infant compared with SB-CAPP teens (AOR 3.75; 95% CI 1.05-13.36). The increased odds of low birth weight for HB-CAPP teens attenuated when prenatal care was adequate and comprehensive (AOR-HB-CAPP: 2.31, 95% CI 0.65-8.24). CONCLUSIONS: School-based prenatal care was associated with significantly lower odds of low birth weight compared with HB-CAPP care. Although selection bias may be a factor in this observational study, our findings suggest that these improved birth outcomes may be mediated through prenatal care adequacy and provision of comprehensive care.

Effects of protocol-driven care versus usual outpatient clinic care on survival rates in patients with type 2 diabetes.

OBJECTIVE: To determine whether clinical outcomes in patients with type 2 diabetes were improved by protocol-driven care in a Diabetes Centre compared with usual outpatient care. STUDY DESIGN: Descriptive analysis of a prospective cohort. PATIENTS AND METHODS: During a median 7-year observational period, 91 patients with type 2 diabetes and no cardiovascular or renal complications were monitored by a nurse and a diabetologist in a clinical trial setting according to a structured protocol. Another 81 patients with comparable clinical characteristics were monitored by generalists at the medical clinic in the same hospital. Clinical end points, defined as death and cardiovascular and renal events, were evaluated in 1997 by review of case records. RESULTS: Patients receiving structured care had lower mortality (relative risk [RR] = 0.21; 95% confidence interval [CI] = 0.07, 0.65; P = .006) than the usual-care group, as well as a lower incidence of combined clinical end points (RR = 0.43; 95% CI = 0.22, 0.84; P = .01). In the usual-care group, patients who had no monitoring of glycosylated hemoglobin or plasma lipid levels during the entire observational period (8.6%) had a 14.6-fold (P < .01) and 15.7-fold (P < .01) increased risk of death and combined clinical end points, respectively, compared with those who had at least one measurement (60.5%). CONCLUSION: Management by protocol-driven care model improved survival and clinical outcomes in patients with type 2 diabetes. Definitive studies are required to confirm these findings and compare the cost effectiveness of these care models.

Identification of the pharmaceutical care issues of rheumatoid arthritis patients in secondary care.

OBJECTIVE: To explore the perceptions of multidisciplinary health care professionals (HCPs) and patients of the pharmaceutical care issues (PCIs) relating to rheumatoid arthritis (RA). DESIGN: Qualitative study using semi-structured one to one interviews and focus groups to explore patient perceptions. Interviews and focus groups were taped and transcribed verbatim, then described and coded for meaning to produce 'in-vivo' codes, which were then grouped to form themes. Nominal group methodology was used to generate and rank a list of HCP perceptions of the key PCIs of RA patients. The PCIs were ranked according to clinical importance and order of occurrence from admission as perceived by the HCP group. SETTING: Rheumatology ward and outpatient clinic in a teaching hospital. MAIN OUTCOME MEASURES: Generation and ranking of PCIs, generation of themes from patient interviews. RESULTS: Optimisation of pain control was identified by the nominal group as being the primary aim for patients on admission and was also the most commonly described symptom by patients. Two PCIs not predicted by the HCPs' nominal group was the frequency of infections and the associated discharge and patients described experiencing 'over-education' by HCPs, which could lead to anxiety. Complementary medicine in conjunction with traditional therapy was raised as a significant health benefit by patients. CONCLUSION: Many patients' views mirrored the PCIs identified by HCPs, but some were not anticipated; the value of patient interviews to ensure appropriate service development was demonstrated. Several PCIs emerged for future incorporation by the multi-disciplinary team into standardised models of pharmaceutical care for use in secondary care and at the secondary/primary care interface for improvement of seamless care. There is a need to target educational interventions and to identify those who will benefit from advice on complementary medicine. Further work is required to develop a tool to identify the educational needs of RA patients and targeting of the information provided. This will help ensure the delivery of pharmaceutical care is designed to match the needs of individual patients.

[Preconception counseling: evaluation of an outpatient clinic at a university hospital]. / Preconceptionele advisering: evaluatie van een polikliniek in een academisch ziekenhuis.

OBJECTIVE: To provide an overview of the outcomes from an outpatients' clinic for preconceptional counselling in the Netherlands and to assess its activities in terms of referrals, referral indications, supplementary investigations, treatment policy and a possible future pregnancy. DESIGN: Retrospective, descriptive. METHOD: Data were collected from the medical records of women who were seen at the outpatients' clinic for preconceptional counselling, University Medical Centre St Radboud, Nijmegen, the Netherlands, during the period 1 January 1996-6 July 2000. RESULTS: Of the 484 women studied, medical records were available for 459 (95%); their median age was 31 years (range: 19-44). Most of the women with one or more risk factors were referred by gynaecologists (65%), followed by general practitioners (17%) and other specialists (14%). The main categories of referral were previous complicated obstetric history, previous fetal abnormality, and chronic maternal disease. Half of the women were subjected to supplementary investigations on the basis of an indication; hyperhomocysteinaemia was diagnosed in 24%, other form of thrombophilia (coagulopathy) in 21% and vitamin deficiency in 18%. The most frequent preconceptional interventions were the correction of hyperhomocysteinaemia by means of administering folic acid or other vitamin supplements and a change of therapy or cessation of therapy for potentially teratogenic medications. CONCLUSION: The outpatients' clinic for preconceptional counselling helped to minimise risk factors for adverse pregnancy outcome amongst high-risk women by providing extensive advice as well as by means of the early detection and treatment of diagnosed abnormalities.

A patient pathway to renal replacement therapy: implementation in the progressive renal insufficiency population.

Care paths and patient pathways are collaborative interdisciplinary tools developed to provide quality care. One goal in progressive renal insufficiency (PRI) care is to provide patients and family members with relevant and timely information to help them cope with medical therapy and lifestyle changes required to slow the progression of renal insufficiency. At Halton Healthcare Services, clinical and patient pathways have been widely used with success. Recognizing the potential benefits of a patient pathway for the PRI population, our interdisciplinary team developed a pathway that outlines the journey to renal replacement therapy. The pathway provides the patient with some insight into the future, as their disease process continues to have impact on their life. Reviewed by a patient within our PRI program during the development process, we have tailored this pathway to meet the needs of this unique population. We predict this patient pathway will have positive impact on the patient's understanding of the role of the PRI clinic and the partnership between the team members, the patient, and the family.

Community hospital homeopathy clinic: audit of the first 12 months activity.

The aim of the study was to examine the activity of a new service providing a homeopathy clinic at a community hospital. This was initiated in a limited way and was served by a relatively inexperienced practitioner. A range of presenting complaints, treatments and outcomes are described. Funding has been maintained by the Health Authority and referrals have continued to be made by the local eligible General Practitioners. The outcomes have been quite good but the default rate has been disappointingly high.

Health Beliefs Model as a template for measurement of intern satisfaction in an ambulatory care clinical training program.

The Health Beliefs Model was originally developed in the 1950s to assess patient behavior toward preventative health strategies, and has evolved into a tool for measuring a variety of health related topics. Interns in an ambulatory care clinical training program were asked to complete a 62 item self-administered questionnaire based on concepts central to a modified Health Beliefs Model for assessment of their satisfaction with their internship program. A logistic regression was undertaken to identify relationships between interns' perceptions toward susceptibility and seriousness of illness, delivery of health care through outpatient clinics, supervisory professional personnel and their overall internship satisfaction rating. The data implies that the modified Health Beliefs Model is of value in predicting intern satisfaction.