Economic evaluation of a dedicated cardiac resynchronisation therapy preassessment clinic.

INTRODUCTION: Patient evaluation before cardiac resynchronisation therapy (CRT) remains heterogeneous across centres and it is suspected a proportion of patients with unfavourable characteristics proceed to implantation. We developed a unique CRT preassessment clinic (CRT PAC) to act as a final review for patients already considered for CRT. We hypothesised that this clinic would identify some patients unsuitable for CRT through updated investigations and review. The purpose of this analysis was to determine whether the CRT PAC led to savings for the National Health Service (NHS). METHODS: A decision tree model was made to evaluate two clinical pathways; (1) standard of care where all patients initially seen in an outpatient cardiology clinic proceeded directly to CRT and (2) management of patients in CRT PAC. RESULTS: 244 patients were reviewed in the CRT PAC; 184 patients were eligible to proceed directly for implantation and 48 patients did not meet consensus guidelines for CRT so were not implanted. Following CRT, 82.4% of patients had improvement in their clinical composite score and 57.7% had reduction in left ventricular end-systolic volume ≥15%. Using the decision tree model, by reviewing patients in the CRT PAC, the total savings for the NHS was £966 880. Taking into consideration the additional cost of the clinic and by applying this model structure throughout the NHS, the potential savings could be as much as £39 million. CONCLUSIONS: CRT PAC appropriately selects patients and leads to substantial savings for the NHS. Adopting this clinic across the NHS has the potential to save £39 million.

Specialist valve clinic in a cardiac centre: 10-year experience.

Aims: Guidelines recommend specialist valve clinics as best practice for the assessment and conservative management of patients with heart valve disease. However, there is little guidance on how to set up and organise a clinic. The aim of this study is to describe a clinic run by a multidisciplinary team consisting of cardiologists, physiologist/scientists and a nurse. Methods: The clinical and organisational aims of the clinic, inclusion and exclusion criteria, and links with other services are described. The methods of training non-clinical staff are detailed. Data were prospectively entered onto a database and the study consisted of an analysis of the clinical characteristics and outcomes of all patients seen between 1 January 2009 and 31 December 2018. Results: There were 2126 new patients and 9522 visits in the 10-year period. The mean age was 64.8 and 55% were male. Of the visits, 3587 (38%) were to the cardiologists, 4092 (43%) to the physiologist/scientists and 1843 (19%) to the nurse. The outcomes from the cardiologist clinics were cardiology follow-up in 460 (30%), referral for surgery in 354 (23%), referral to the physiologist/scientist clinic in 412 (27%) or to the nurse clinic in 65 (4.3%) and discharge in 230 (15%). The cardiologist needed to see 6% from the nurse clinic and 10% from the physiologist/scientist clinic, while advice alone was sufficient in 10% and 9%. Conclusion: A multidisciplinary specialist valve clinic is feasible and sustainable in the long term.

Nasal fractures: a dedicated clinic providing reduction under local anaesthesia improves time to manipulation.

INTRODUCTION: Guidelines for nasal injury state that assessment should be at 7-10 days post-injury and manipulation within 14 days. We performed a plan, do, study, act improvement cycle to assess whether a dedicated nasal fracture service led to better outcomes. MATERIALS AND METHODS: A retrospective study was carried out of all patients undergoing manipulation under anaesthesia for nasal trauma between February 2013 and December 2016 in a district general hospital. A dedicated nasal fracture clinic providing manipulation under local anaesthesia was implemented followed by a prospective study of all patients presenting to the clinic between February and November 2017. Main outcome measures included time from injury to otolaryngology assessment, time from injury to manipulation and incidence of secondary septorhinoplasty. RESULTS: The retrospective series involved 525 patients including 381 males (72.6%) and 144 females (27.4%). Mean time from injury to assessment was 10 days. Mean time from injury to surgery was 14.5 days. Mean time from assessment to surgery was five days. The incidence of septorhinoplasty was 2.3%. The prospective series involved 119 patients including 78 males (65.5%) and 41 females (34.5%). Following implementation of a nasal fracture clinic, mean time from injury to assessment and manipulation was 6.1 days and 5.4% of patients underwent septorhinoplasty for secondary deformity. DISCUSSION: Implementation of a nasal fracture clinic providing reduction under local anaesthesia reduced the time to assessment and manipulation. The incidence of septorhinoplasty is low following reduction under general or local anaesthesia. Assessment earlier than seven days is feasible and advice for referral can be changed accordingly.

Oral status of HIV-infected children aged 12 years or younger who attended a Paediatric Infectious Diseases Clinic in Cape Town.

BACKGROUND: Children continue to suffer from the impact of the human immunodeficiency virus-acquired immunodeficiency syndrome (HIV/AIDS) pandemic. In Cape Town, these children receive medical care including antiretroviral therapy from facilities like Tygerberg Hospital's Paediatric Infectious Diseases Clinic. HIV-infected children may experience an increased caries experience when compared with their healthy peers. AIM: The aim of this study was to determine the oral health status of HIV-infected children younger than 12 years receiving antiviral drugs at the Paediatric Infectious Diseases Clinic. DESIGN: A cross-sectional survey was conducted among children aged between 2 and 12 years presenting at this clinic. Caregivers were interviewed to obtain information regarding health seeking behaviour, oral hygiene practices and dietary habits. A single clinician undertook a standardized clinical intraoral examination according to the World Health Organization guidelines, with modifications. RESULTS: Sixty-six children were recruited. A high prevalence of dental caries (78.8%) and an unmet treatment need of 90.4% were recorded among the participants. Most children had never visited the dentist, and those who did had mainly received emergency dental care. CONCLUSION: The high prevalence of severe dental caries in this population highlights the need for oral health awareness and the inclusion of oral health care in the comprehensive care of children with HIV. WHY THIS PAPER IS IMPORTANT TO PAEDIATRIC DENTISTS: The study highlights the importance of collaborating with health professions outside of dentistry. Doctors and nurses are often the first health professionals to come into contact with children with special needs. They should therefore be made aware of the early signs of decay so that these patients can be referred for dental treatment timeously. Holistic management of children with special healthcare needs is essential to improve their overall well-being.

Saturday multidisciplinary hemodialysis access clinics to enhance patient care.

Fragmentation of outpatient care is a substantial barrier to creation and maintenance of hemodialysis access. To improve patient accessibility, satisfaction, and multidisciplinary provider communication, we created a monthly Saturday multidisciplinary vascular surgery and interventional nephrology access clinic at a tertiary care hospital in a major urban area for the complicated hemodialysis patient population. The study included patients presenting for new access creation as well as those who had previously undergone access surgery. Staffing included two to three interventional nephrologists, two to three vascular surgeons, one medical assistant, one research assistant, and one practice assistant. Patient satisfaction and perception of the clinic was measured using surveys during six of the monthly Saturday hemodialysis clinics. A total of 675 patient encounters were completed (18.2 average/clinic ±6.3 standard deviation) from August 2016 to August 2019. All patients were seen by both disciplines. The average no-show rate was 19.9% throughout the study period. Patient satisfaction in all measures was consistently high with the Saturday clinic. Providers were also assayed, and they generally valued the real-time, multidisciplinary care plan generation, and its subsequent efficient execution. Saturday multidisciplinary hemodialysis access clinics offer high provider and patient satisfaction and streamlined patient care. However, no-show rates remain relatively high for this challenging patient population.

A Successful Walk-In Psychiatric Model for Integrated Care.

PURPOSE: Accommodating walk-in psychiatry visits in primary care can improve access to psychiatric care for patients from historically underserved groups. We sought to determine whether a walk-in psychiatry model embedded within an integrated care practice could be sustained over time, and to characterize the patients who accessed care through it. METHODS: We reviewed electronic health records linked to 811 psychiatry encounters in an integrated care practice between October 1, 2015 and September 30, 2017. Primary outcomes were the initial and return psychiatry encounters per month. Secondary outcomes were the demographics and diagnoses of patients who accessed their initial visits through walk-in sessions and scheduled appointments. RESULTS: 490 initial psychiatry evaluations and 321 return encounters took place over the 2-year study period. The volume of initial psychiatry evaluations per month did not significantly change, but the volume of psychiatry follow-up encounters significantly increased after the walk-in session expanded. Medicaid recipients (OR, 1.9; 95% CI, 1.2 to 3.0); individuals without a college degree (OR, 1.7; 95% CI, 1.1 to 2.5); individuals who were single, divorced, or separated (OR, 1.7; 95% CI, 1.1 to 2.5); and individuals who identified as Black or Hispanic (OR, 2.5; 95% CI, 1.7 to 3.6) were more likely to access an initial psychiatry evaluation through a walk-in session as opposed to a scheduled appointment. CONCLUSIONS: Providing psychiatric care on a walk-in basis in integrated care is sustainable. Patients from historically underserved groups may access psychiatric care disproportionately through a walk-in option when it is available.

Implementation of a student pharmacist-driven medication history service for ambulatory oncology patients in a large academic medical center.

OBJECTIVE: Patients who have an up-to-date and accurate medication list are less susceptible to medication errors and allow care teams to make more informed treatment decisions. Through utilizing student pharmacists to provide medication history services, we anticipate improved patient safety and overall quality of patient care. The purpose of this project was to implement a medication history service for ambulatory oncology patients of the Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins Hospital. METHODS: A phased approach was utilized to implement a standardized operating procedure for completing medication histories in ambulatory oncology patients. Data collection included number of total medication discrepancies, percentage of patients with high-risk medications, and high-risk medication classes involved in discrepancies. Additionally, time data were collected, including time spent calling the patient, completing patient work up, and preceptor oversight. RESULTS: Students completed medication histories for 60 patients; 83% of patients had at least one discrepancy with 21% of those discrepancies involving a high-risk medication. High-risk medications involved in discrepancies included oral chemotherapeutic agents, anticoagulants, insulin, and opioids. CONCLUSION: The majority of patients seen had at least one medication discrepancy that was identified and corrected through the medication history service. By correcting the discrepancy, the likelihood of medication errors occurring was decreased. Continuous workflow changes are being made to identify the number and type of resources to expand the service to all appropriate ambulatory oncology patients at the Sidney Kimmel Comprehensive Cancer Center.

Understanding case mix across three paediatric services: could integration of primary and secondary general paediatrics alter walk-in emergency attendances?

OBJECTIVE: To understand the case mix of three different paediatric services, reasons for using an acute paediatric service in a region of developing integrated care and where acute attendances could alternatively have been managed. METHODS: Mixed methods service evaluation, including retrospective review of referrals to general paediatric outpatients (n=534) and a virtual integrated service (email advice line) (n=474), as well as a prospective survey of paediatric ambulatory unit (PAU) attendees (n=95) and review by a paediatric consultant/registrar to decide where these cases could alternatively have been managed. RESULTS: The case mix of outpatient referrals and the email advice line was similar, but the case mix for PAU was more acute. The most common parental reasons for attending PAU were referral by a community health professional (27.2%), not being able to get a general practitioner (GP) appointment when desired (21.7%), wanting to avoid accident and emergency (17.4%) and wanting specialist paediatric input (14.1%). More than half of PAU presentations were deemed most appropriate for community management by a GP or midwife. The proportion of cases suitable for community management varied by the reason for attendance, with it highestl for parents reporting not being able to get a GP appointment (85%), and lowest for those referred by community health professionals (29%). CONCLUSIONS: One in two attendances to acute paediatric services could have been managed in the community. Integration of paediatric services could help address parental reasons for attending acute services, as well as facilitating the community management of chronic conditions.

Perceived factors influencing hospital-based primary care clinic referrals to community health medical nutrition therapy: An exploratory study.

Primary care clinics provide an array of diagnostic and clinical services that assist patients in preventing the onset or managing acute and chronic conditions. Some chronic conditions such as high blood pressure, high cholesterol, and type 2 diabetes require primary care professionals to seek additional medical intervention from registered dieticians. This study explored beliefs, attitudes, and practices of medical and administrative professionals in primary care clinics encountering patients who are potential candidates for ongoing nutrition education or counselling. Five focus groups with primary care providers and clinical staff (n = 24) were conducted to identify perceived intra-organisational factors influencing initiation of community health medical nutrition therapy (MNT) referrals. Lack of clarity regarding community health dieticians' role in chronic disease management was the primary finding for the absence of MNT referrals. Insurance-imposed constraints, perceived patient readiness to change, and service inaccessibility were revealed as barriers that influence referrals to both community health and specialty care dieticians. This study underscores the importance of identifying organisational and interpersonal barriers that influence the initiation of community health MNT referrals. Understanding these barriers can create stronger interprofessional collaboration between primary care providers and community health dieticians.

Integrating family planning services into HIV care: use of a point-of-care electronic medical record system in Lilongwe, Malawi.

BACKGROUND: Integrating family planning (FP) services into human immunodeficiency virus (HIV) clinical care helps improve access to contraceptives for women living with HIV. However, high patient volumes may limit providers' ability to counsel women about pregnancy risks and contraceptive options. OBJECTIVES: To assess trends in the use of contraceptive methods after implementing an  electronic medical record (EMR) system with FP questions and determine the reasons for non-use of contraceptives among women of reproductive age (15-49 years) receiving antiretroviral therapy (ART) at the Martin Preuss Center clinic in Malawi. METHODS: In February 2012, two FP questions were incorporated into the ART EMR system (initial FP EMR module) to prompt providers to offer contraceptives to women. In July 2013, additional questions were added to the FP EMR module (enhanced FP EMR) to prompt providers to assess risks of unintended pregnancies, solicit reasons for non-use of contraceptives and offer contraceptives to non-pregnant women . We conducted a retrospective, longitudinal cohort study using the EMR routinely collected data. The primary outcome was the use of any modern contraceptive method. Descriptive statistics were used to describe the study population and report trends in contraceptive use during the initial and enhanced study periods. RESULTS: Between February 2012 and December 2016, in HIV clinics, 20,253 women of reproductive age received ART, resulting in 163,325 clinic visits observations. The proportion of women using contraceptives increased significantly from 18% to 39% between February 2012 and June 2013, and from 39% to 67% between July 2013 and December 2016 (chi-square for trend p < 0.001). Common reasons reported for the non-use of contraceptives among those at risk of unintended pregnancy were: pregnancy ambivalence (n = 234, 51%) and never thought about it (n = 133, 29%). CONCLUSION: Incorporating the FP EMR module into HIV clinical care prompted healthcare workers to encourage the use of contraceptives.

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.

Impact of a general practitioner-led integrated model of care on the cost of potentially preventable diabetes-related hospitalisations.

AIM: To estimate potential savings for Australia's health care system through the implementation of an innovative Beacon model of care for patients with complex diabetes. METHODS: A prospective controlled trial was conducted comparing a multidisciplinary, community-based, integrated primary-secondary care diabetes service with usual care at a hospital diabetes outpatient clinic. We extracted patient hospitalisation data from the Queensland Hospital Admitted Patient Data Collection and used Australian Refined Diagnosis Related Groups to assign costs to potentially preventable hospitalisations for diabetes. RESULTS: 327 patients with complex diabetes referred by their general practitioner for specialist outpatient care were included in the analysis. The integrated model of care had potential for national cost savings of $132.5 million per year. CONCLUSIONS: The differences in hospitalisations attributable to better integrated primary/secondary care can yield large cost savings. Models such as the Beacon are highly relevant to current national health care reform initiatives to improve the continuity and efficiency of care for those with complex chronic disease in primary care.

Electronic Care Coordination From the Preoperative Clinic.

Fragmented and variable perioperative care exposes patients to unnecessary risks and handoff errors. The perioperative surgical home aims to optimize quality, value-based care. We performed a retrospective evaluation of how a preoperative assessment center could coordinate care through e-mails sent to a patient's healthcare team that initiate discussion on critical clinical information. During 100 clinic days on which 8122 patients were evaluated, 606 triggered e-mails, with a potential impact on 19 elements across the perioperative care spectrum. Four cases were canceled, and 42 cases were rescheduled. By fostering information exchange, these communications could advance patient-centered, value-enhanced quality and safety outcomes.

[How to convince the head of department and managing director of the importance of specialised headache clinics]. / Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.

In spite that headache is, by far, the most frequent reason for neurological consultation and that the diagnosis and treatment of some patients with headache is difficult, the number of headache clinics is scarce in our country. In this paper the main arguments which should allow us, as neurologists, to defend the necessity of implementing headache clinics are reviewed. To get this aim we should first overcome our internal reluctances, which still make headache as scarcely appreciated within our specialty. The facts that more than a quarter of consultations to our Neurology Services are due to headache, that there are more than 200 different headaches, some of them actually invalidating, and the new therapeutic options for chronic patients, such as OnabotulinumtoxinA or neuromodulation techniques, oblige us to introduce specialised headache attendance in our current neurological offer. Even though there are no definite data, available results indicate that headache clinics are efficient in patients with chronic headaches, not only in terms of health benefit but also from an economical point of view.

TITLE: Como convencer al jefe de servicio y al gerente de la importancia de las unidades/consultas especializadas de cefaleas.A pesar de que la cefalea es, con diferencia, el principal motivo neurologico de consulta, y de la complejidad diagnostica y terapeutica de algunos pacientes, el numero de consultas monograficas de cefalea (CC) y de unidades de cefalea (UC) es muy reducido en nuestro pais. En este articulo pasaremos revista a los principales argumentos que nos permitan, como neurologos, defender la necesidad de la implementacion de una CC/UC, dependiendo de la poblacion que se debe atender, en todos nuestros servicios de neurologia. Para ello deberemos, en primer lugar, vencer las reticencias internas, que hacen que la cefalea sea aun poco apreciada y atractiva dentro de nuestra especialidad. El hecho de que la cefalea justifique mas de un cuarto de las consultas a un servicio de neurologia estandar de nuestro pais y de que existan mas de 200 cefaleas diferentes, algunas de ellas realmente invalidantes, y las nuevas opciones de tratamiento para pacientes cronicos, como la OnabotulinumtoxinA para la migraña cronica o las tecnicas de neuromodulacion, obligan a introducir dentro de nuestras carteras de servicios la asistencia especializada en cefaleas. Aunque no disponemos de datos incontrovertibles, existen ya datos suficientes en la literatura que indican que esta atencion es eficiente en pacientes con cefaleas cronicas no solo en terminos de salud, sino tambien desde el punto de vista economico.

[Organisation of headache units from a multidisciplinary point of view]. / Organizacion de las unidades de cefalea desde un punto de vista multidisciplinar.

Headache units have come into being to respond to the need to address the treatment of patients with complex headaches in a multidisciplinary manner. Although headaches are one of the most prevalent medical pathologies, it is surprising how little is being done to foster the development of such units. Within the multidisciplinary organisation, the role of the neurologist with adequate training in this field is essential. He or she is the person responsible for receiving, directing, supervising and coordinating the treatment, together with other medical specialties. The basic core of the team should consist of a psychiatrist, psychologist and physiotherapist. Their joint coordinated action generates an objective improvement in the pain over and beyond that achieved with each isolated treatment.

TITLE: Organizacion de las unidades de cefalea desde un punto de vista multidisciplinar.Las unidades de cefaleas surgen ante la necesidad de abordar de forma multidisciplinar el tratamiento de pacientes con dolores de cabeza complejos. A pesar de que las cefaleas son una de las patologias medicas mas prevalentes, es llamativa la poca promocion que existe para su desarrollo. Dentro de la organizacion multidisciplinar, el papel del neurologo debidamente formado en este campo es crucial. Es la persona encargada de recibir, dirigir, supervisar y coordinar el tratamiento, junto con otras especialidades medicas. Se debe contar con la participacion del psiquiatra, del psicologo y del fisioterapeuta como nucleo basico. Su actuacion conjunta y coordinada genera de forma objetiva una mejoria del dolor frente a cada tratamiento de forma aislada.

A comprehensive palliative care program at a tertiary cancer center in Jordan.

CONTEXT: The palliative care program in King Hussein Cancer Center (KHCC) is growing rapidly to serve the needs of patients with cancer and their families. OBJECTIVE: To describe the KHCC palliative care program and its integration into the oncology care. METHODS: Narrative review of our palliative care program. RESULTS: Patients with cancer at KHCC have access to an interprofessional palliative care at different settings. In 2012, the inpatient team saw 400 consultations and 979 referrals and admissions. The outpatient clinic had a total of 1133 patient visits. The home care program provided a total of 1501 visits. Our program is a regional center for education and training and actively conducts research. CONCLUSION: Our palliative care program may be a model for successful delivery of comprehensive cancer care in the Middle East.

[Better coordination between primary care, community settings and diabetes outpatient clinic for patients with type 2 diabetes].

Integrated care programmes for patients with type 2 diabetes can be successfully implemented by planning the programmes in coordination between the sectors primary care, community settings and diabetes outpatient clinic, and with involvement of leaders and employees. Our project has resulted in: 1) more patients with type 2 diabetes receiving diabetes management courses, 2) improved diabetes management of primary care, and 3) improved confidence and respect between sectors involved in diabetes care.

[Ambulatory healthcare center in the context of a rheumatology clinic]. / Rheumatologisches Medizinisches Versorgungszentrum an einer Akutklinik.

BACKGROUND: The chronic nature of most rheumatic diseases, the complexity of the course of the disease and types of therapy used necessitate a close interlocking of inpatient and outpatient treatment options. Some years ago in Germany the interdisciplinary outpatient and inpatient treatment was facilitated by statutory regulations. As the number of rheumatologists in private practice is not sufficient to provide adequate rheumatologic outpatient healthcare, the improvement of interface points between outpatient and inpatient care becomes more important. There are various ways for hospitals to take part in outpatient care, one of which is the foundation of an ambulatory healthcare center. METHODS: The introduction and integration of a medical healthcare center is described using an example. RESULTS: Against the background of insufficient rheumatology outpatient care in Cologne a city with 1 million inhabitants, the establishment of a rheumatology outpatient healthcare center at Porz am Rhein which is the only rheumatology clinic in this region is described.

Oncology rehabilitation outcomes over time: a mixed-methods approach.

PURPOSE/OBJECTIVES: To evaluate an oncology rehabilitation program over time. DESIGN: A cross-sectional, retrospective program evaluation using a mixed-methods approach. SETTING: An outpatient oncology rehabilitation program housed in an urban, hospital-based comprehensive cancer center in Alaska. SAMPLE: 102 cancer survivors who had completed a 10-week oncology rehabilitation program (mean time since completion was 2.5 years). METHODS: Participants completed a mailed, 28-item retrospective survey to collect perceived activity level recalled at various points in time as well as program perceptions. Open-ended questions elicited narrative comments about motivators and barriers. The Medical Outcomes Study (MOS) SF-36® was completed before and after the program. MAIN RESEARCH VARIABLES: Health-related quality of life, perceived health status, activity level, motivators, barriers, and program perceptions. FINDINGS: A small increase in level of activity from precancer to the current time (postrehabilitation) (z = -3.1, p < 0.01) was reported. Most and least helpful motivators emerged from the narrative data, resulting in the shared interpretation of "I have my life back." CONCLUSIONS: Program motivators were effective in helping cancer survivors maintain some increased activity and retain positive perceptions well after the completion of the program. IMPLICATIONS FOR NURSING: Survivors who complete a rehabilitation program retain a sense of restoration and caring, and some engage in physical activity over time. Adapting the program based on insights into the survivor perspective may assist oncology rehabilitation clinicians to promote optimum physical activity and sustain healthful change.