Ambulatory Care Model Research Articles

Closing Gaps in Lifestyle Adherence for Secondary Prevention of Coronary Heart Disease

The secondary prevention (SP) of coronary heart disease (CHD) has become a major public health and economic burden worldwide. In the United States, the prevalence of CHD has risen to 18 million, the incidence of recurrent myocardial infarctions (MI) remains high, and related healthcare costs are projected to double by 2035. In the last decade, practice guidelines and performance measures for the SP of CHD have increasingly emphasized evidence-based lifestyle (LS) interventions, including healthy dietary patterns, regular exercise, smoking cessation, weight management, depression screening, and enrollment in cardiac rehabilitation. However, data show large gaps in adherence to healthy LS behaviors and low rates of enrollment in cardiac rehabilitation in patients with established CHD. These gaps may be related, since behavior change interventions have not been well integrated into traditional ambulatory care models in the United States. The chronic care model, an evidence-based practice framework that incorporates clinical decision support, self-management support, team-care delivery and other strategies for delivering chronic care is well suited for both chronic CHD management and prevention interventions, including those related to behavior change. This article reviews the evidence base for LS interventions for the SP of CHD, discusses current gaps in adherence, and presents strategies for closing these gaps via evidence-based and emerging interventions that are conceptually aligned with the elements of the chronic care model.

Potentially inappropriate prescribing in older adults with advanced chronic kidney disease.

Older adults with chronic kidney disease (CKD) are at heightened risk for polypharmacy. We examined potentially inappropriate prescribing in this population and whether introducing pharmacists into the ambulatory kidney care model was associated with improved prescribing practices. Retrospective cohort study using linked administrative databases. We included patients with an eGFR ≤30 mL/min/1.73 m2 ≥66 years of age followed in multidisciplinary kidney clinics in Ontario, Canada (n = 25,016 from 28 centres). The primary outcome was the absence of a statin prescription or the receipt of a potentially inappropriate prescription defined by the American Geriatric Society Beers Criteria® and a modified Delphi panel that identified key drugs of concern in CKD. We calculated the crude cumulative incidence and incidence rate for the primary outcome and used change-point regression to determine if a change occurred following pharmacist introduction. There were 6,007 (24%) and 16,497 patients (66%) not prescribed a statin and with ≥1 potentially inappropriate prescription, respectively. The rate of potentially inappropriate prescribing was 125.6 per 100 person-years and was higher in more recent years. The change-point regression analysis included 2,275 patients from two centres. No immediate change was detected at pharmacist introduction, but potentially inappropriate prescribing was increasing pre-pharmacist introduction, and this rising trend was reversed post-pharmacist introduction. The incidence of potentially inappropriate prescribing still remained high post-pharmacist introduction. Potentially inappropriate prescribing practices were common. Incorporating pharmacists into the kidney care model may improve prescribing practices. The role of pharmacists in the ambulatory kidney care team warrants further investigation in a randomized controlled trial.

A feasibility assessment of an ambulatory care pathway for cellulitis at a tertiary referral centre in the Republic of Ireland

Abstract Introduction There is a need for the development of more ambulatory care pathways to reduce the number of bed-days utilized by ambulatory care sensitive conditions in hospitals in Ireland. Healthcare policy and strategy has changed to reflect this. Our aim was to determine if an ambulatory care pathway for the management of cellulitis would be feasible in our tertiary referral centre. Methods We searched hospital coding data to identify all admissions with cellulitis from 1/1/2018 to 31/12/2018 in our tertiary referral centre. We estimated the cost of cellulitis admissions using guidelines from the Healthcare Pricing Office in Ireland. We used guidance from the Department of Public Expenditure and Reform to calculate the cost of staff in a proposed ambulatory care model. Results We identified 249 episodes of care with cellulitis in 2018. 89.6% (223/249) were emergency episodes of care. A total of 2372 bed-days was utilized by emergency episodes of care at a cost of €1,126,369–1,129,823. The median cost of an emergency episode of care due to cellulitis was €2291 (IQR 2291–5594) with a mean cost per bed-day of €475–476. Overall, there was neither sepsis nor a surgical intervention coded in 85.2% (190/223) of emergency episodes of care. We identified a cohort of 23.8% (53/223) of emergency episodes of care that had a length of stay of 1–3 days which could potentially have been managed using an ambulatory care pathway. Conclusion Even if only a small proportion of cases were ambulated there are significant savings in terms of bed-days and costs to be made. An ambulatory care pathway for cellulitis should be established in our tertiary referral centre and this methodology could be used to inform resourcing of pathways elsewhere.

PNS103 DIRECT PRIMARY CARE: COMPARISON OF QUALITY METRICS TO AHRQ, CDC, AND HEALTHY PEOPLE 2020 INDICATORS

Direct Primary Care (DPC) is an evolving patient-centered, prevention-oriented, fixed-fee-for-membership ambulatory care model designed to facilitate direct patient-provider communication and contact. The study objective was to identify primary care quality (PCQ) metrics from electronic health records (EHR) and claims data for comparison to measures from similar populations benchmarked by the Agency for Healthcare Research and Quality’s National Healthcare Quality and Disparities Reports (AHRQ-NHQDR), the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (CDC-BRFSS), and the Office of Disease Prevention and Health Promotion’s Healthy People 2020.

Assessing the safety of autologous stem cell transplant pathway via ambulatory care for patients with multiple myeloma

High-dose chemotherapy (HDT) with autologous stem cell transplantation (ASCT) is the standard of care for eligible multiple myeloma (MM) patients with improved progression-free and overall survival. We reviewed the ambulatory care unit pathway for MM patients who underwent HDT/ASCT in a tertiary hospital to assess safety efficacy and outcomes. We concluded that the ambulatory care model offered for MM patients undergoing HDT/ASCT is a safe alternative pathway and highlighted further improvements.

AB150. The use of the ambulatory care model for distal radius fractures in University Hospital Limerick

Background: The Health Service Excutive (HSE) National Model of Care for Trauma and Orthopaedics and the British Orthopaedic Association both recommend the use of an ambulatory care model for the management of distal radius fractures. The ambulatory care model recommends suitable patients should be discharged home following diagnosis and return as a planned day case admission for their definitive treatment to avoid unnecessary inpatient stays and bed blocking. We identified an issue as there is no current pathway to facilitate the ambulatory care model in University Hospital Limerick (UHL) and as such we conducted this audit to identify the impact of this service deficit on patients and the health system.

Long-term outcomes of acute kidney injury and strategies for improved care.

Acute kidney injury (AKI), once viewed predominantly as a self-limited and reversible condition, is now recognized as a growing problem associated with significant risks of adverse long-term health outcomes. Many cohort studies have established important relationships between AKI and subsequent risks of recurrent AKI, hospital re-admission, morbidity and mortality from cardiovascular disease and cancer, as well as the development ofchronic kidney disease and end-stage kidney disease. In both high-income countries (HICs) and low-income or middle-income countries (LMICs), several challenges exist in providing high-quality, patient-centered care following AKI. Despite advances in our understanding about the long-term risks following AKI, large gaps in knowledge remain about effective interventions that can improve the outcomes of patients. Therapies for high blood pressure, glycaemic control (for patients with diabetes), renin-angiotensin inhibition and statins might be important in improving long-term cardiovascular and kidney outcomes after AKI. Novel strategies that incorporate risk stratification approaches, educational interventions and new models of ambulatory care following AKI have been described, and some of these are now being implemented and evaluated in clinical studies in HICs. Care for AKI in LMICs must overcome additional barriers due to limited resources for diagnosis and management.

"Cancer Life ReiMagined:" The CaLM model of whole-person cancer care.

74 Background: Despite advances in cancer treatment, the orientation of our health system does not address the whole cancer patient or support the wellbeing of the heart, soul, and mind. We launched the CaLM Model of Whole Person Cancer Care, an oncology medical home approach that integrates high acuity, sub-specialty clinical cancer care with comprehensive, ongoing supportive care. The CaLM Model operationalizes the six components in the conceptual framework set forth in the NASEM’s 2013 report. Delivering High-Quality Cancer Care. Methods: Beginning December 2018, we piloted a “flipped” ambulatory care model in GYN and GI oncology delivering daily care through a subset of providers, the SWAT Team: a palliative NP, med onc NP, clinical social worker, and navigator. The SWAT Team triages all physical and social needs. As opposed to anchoring care with the oncologist and referring the patient out to social services, the SWAT team anchors care and the oncologist plugs in for treatment planning. The CaLM Model also utilizes coordinated, interdisciplinary care including financial and fertility navigation, nutrition, genetic counseling, pharmacy, and psychiatry, to manage the patient’s needs via a team-based approach by assessing and addressing the patient’s needs according to their values and preferences. We designed a new clinical and psychosocial assessment tool and patient-facing care plan; launched a Multi-Disciplinary “whole-person” case review process with all interdisciplinary providers and measured patient reported outcomes using the FACT-G, PHQ, GAD, and MD Anderson Symptom Inventory at baseline (initial visit) and every clinical visit. Measured at initial visit and every 6 months. Results: Early data show that the CaLM Model reduces patient symptom burden while improving quality of life. Conclusions: The CaLM Model is an efficient use of resources, compared to a traditional oncologist-focused model of cancer care. Further research is underway to assess cost benefit to the system, the patient and the payers. Ultimately, the CaLM Model may shift the paradigm of cancer care by demonstrating the feasibility and effectiveness of a patient-centered model of care delivery that builds a foundation for a value-based payment model.

Single-visit surgery: An evaluation from an institutional perspective

Background/PurposeElective ambulatory surgical care traditionally involves three independent visits. Single-Visit Surgery (SVS) is an alternative surgical model that consolidates care into one visit. Evaluation of the effect of this novel program on hospital operations is limited. The objective of this study was to analyze SVS from an institutional perspective. MethodsWe retrospectively reviewed patients scheduled for SVS at a freestanding children’s hospital between January 2016 and August 2017. Data collected included clinic “no show” rates, operating room (OR) utilization, reimbursement rates, and postoperative visits. ResultsThere were 89 patients scheduled for SVS, of which 63% (n=56) were male, and the median age was 6 years [IQR, 4–9]. The SVS clinic “no show” rate was 2% (n=2) compared to the pediatric surgery clinic “no show” rate of 11% (p=0.01). The SVS OR block utilization rate was 90%. Payment was received from third-party payors for 92% of consultations and 100% of operative procedures without securing prior authorization. Postoperatively 25% (n=17) of patients presented to clinic for follow-up, and one child presented to the emergency department for vomiting. There were no hospital admissions. ConclusionSingle-Visit Surgery is an alternative model of ambulatory surgical care that improves institutional efficiency while also enhancing the patient experience. Type of studyRetrospective cohort review Level of evidenceIII

Cost of three models of care for drug-resistant tuberculosis patients in Nigeria

BackgroundNigeria accounts for a significant proportion of the global drug-resistant tuberculosis (DR-TB) burden, a large proportion of which goes untreated. Different models for managing DR-TB treatment with varying levels of hospitalization are in use across Nigeria, however costing evidence is required to guide the scale up of DR-TB care. We aimed to estimate and compare the costs of different DR-TB treatment and care models in Nigeria.MethodsWe estimated the costs associated with three models of DR-TB treatment and care: Model (A) patients are hospitalized throughout the 8-month intensive phase, Model (B) patients are partially hospitalized during the intensive phase and Model (C) is entirely ambulatory. Costs of treatment, in-patient and outpatient care and diagnostic and monitoring tests were collected using a standardized data collection sheet from six sites through an ingredient’s approach and cost models were based on the Nigerian National Tuberculosis, Leprosy and Buruli Ulcer Guideline - Sixth Edition (2014) and Guideline for programmatic and clinical management of drug-resistant tuberculosis in Nigeria (2015).ResultsAssuming adherence to the Nigerian DR-TB guidelines, the per patient cost of Model A was $18,528 USD, Model B $15,159 USD and Model C $9425 USD. Major drivers of cost included hospitalization (Models A and B) and costs of out-patient consultations and supervision (Model C).ConclusionUtilizing a decentralized ambulatory model, is a more economically viable approach for the expansion of DR-TB care in Nigeria, given that patient beds for DR-TB treatment and care are limited and costs of hospitalized treatment are considerably more expensive than ambulatory models. Scale-up of less expensive ambulatory care models should be carefully considered in particular, when treatment efficacy is demonstrated to be similar across the different models to allow for patients not requiring hospitalization to be cared for in the least expensive way.

Single-Visit Surgery Offers Added Convenience and Excellent Family Satisfaction

BackgroundThe traditional model for elective ambulatory surgical care includes three separate visits to the surgeon: an initial consultation, a second for outpatient surgery, and a third for postoperative follow-up. Single-Visit Surgery (SVS) is an alternative model of ambulatory surgical care that consolidates care into a single appointment where patients with straightforward surgical problems are evaluated in the morning and undergo a surgical procedure later that same afternoon. In April 2016, SVS was introduced at a tertiary-care freestanding children's hospital. Our objective for this study was to evaluate our early experience and conduct a survey of our patient's caregivers to evaluate their satisfaction with SVS. Materials and methodsWe retrospectively reviewed the medical records of patients that were seen as part of SVS from April 2016 through December 2016. Data collected included demographics, diagnoses, procedures performed, clinical outcomes, and distance traveled to the hospital. In addition, adult caregivers of SVS patients were asked to participate in a telephone survey. ResultsThere were 43 patients seen through SVS during the study period. The median age was 7 y. Of the 43 patients evaluated through SVS, 40 (93%) of them underwent surgery. Of the 40 patients that had surgery, 27 (68%) of the families participated in the telephone survey. Of those responding, 93% were strongly satisfied, and 7% were satisfied with the care through SVS. All families said they would recommend the SVS program to a friend. ConclusionsSVS is an alternative model of ambulatory surgical care that adds convenience to the patient experience and results in excellent family satisfaction.

Less time in Hospital; more time at home

Introduction: Navigating the maze of the health system can be challenging for families of children with chronic and complex conditions. These children often slip through the gaps, are managed by multiple teams and become disengaged with primary and local services. The Sydney Children’s Hospitals Network (SCHN) Care Coordination Service helps care teams partner with families and local health services so that children with chronic and complex conditions spend less time in hospital and more time at home. Practice change implemented (methodology): The SCHN Care Coordination program (Kids GPS – Guided Personalised Services) applies a quality improvement framework using ‘Plan, Do, Study, Act’ (PDSA) cycles to continually implement, evaluate and modify approaches to care coordination. The service consists of nurses and social workers – ‘the Care Coordinators’ who work in partnership with the hospital, community and family ‘lead’ to develop a contemporaneous care plan. A strategy of combining ambulatory models of care and a 24/7 telephone service has made this program more robust. The program was implemented in February 2014. Outcomes are measured on a monthly basis with data comparison driving further PDSA cycles. Aim / targeted population: To implement a model of care coordination for children with medical complexity that aims to improve efficiency and patient outcomes by supporting families to navigate services/providers within SCHN, Local Health Districts (LHDs) and Primary Health Networks (PHNs). Care Coordination for this cohort of children intends to reduce avoidable hospital attendance and improve the integration of care between community health providers and the hospital. Highlights (outcomes): Kids GPS has achieved significant outcomes measured both in terms of hospital encounters saved and patient-focussed outcomes. The program currently has 446 children enrolled. Between July 2015 and June 2017, the service demonstrated: 875 hospital encounters saved, equating to approximately $977,000 in financial savings for SCHN 51,500 KM travel saved for families and 370 school absences prevented 204 ED presentations avoided, with implementation of a 24/7 Hotline in August 2016 increasing the average ED presentations saved per month from 1.6 to 16.7 Analysis of the past six months data (Jan-Jun 2017) demonstrates a 400% increase in encounters saved (448 compared to 111 between Jul-Dec 2016) following service design changes though various PDSA cycles. Sustainability and transferability: Members of the SCHN Care Coordination team are part of the Children’s Healthcare Australasia (CHA) Complex Care Special Interest Group. The networking from this group has resulted in referrals of complex patients moving interstate, enabling care coordination to commence prior to the patient relocating. This has proven an innovative way of inter-state agency collaboration. It is anticipated that future funding will lead to additional care coordinators with a focus on aboriginal patients/families, and children/youth presenting frequently to the ED for mental health or behavioural disorders. Conclusion: Effective care coordination can significantly benefit the lives of patients/families with chronic and complex conditions. Key lessons learned: Combining ambulatory models of care with care coordination makes the integrated model of care more robust 24/7 hotline access providesa further safety net to empower parents/carers Outcome measurements that are patient focussed helps to create organisational cultural change

REDUCING ER USE THROUGH A TRAINEE-DESIGNED, INTERPROFESSIONAL CARE GROUP FOR HIGH-UTILIZING CHRONICALLY ILL PATIENTS: A PILOT PROGRAM.

Healthcare utilization is skewed to a subset of high-need, high-use patients, but optimal models of care are not known. To reduce emergency room (ER) use and hospital readmissions, trainees designed an innovative model of care delivery for chronically ill, high-utilizing adult patients. Enrolled patients (N = 65) joined an interprofessional care program (nutrition, behavioral health, pharmacy, and care coordination), located in a single ambulatory clinic with extended hours. Evaluated by generalized linear mixed-effects models, the primary outcome of all-cause ER visits showed a significant decreasing trend after enrollment, from an increasing odds of ER visits (OR 1.07) in the 12-months prior to the program, compared to a decreasing trend post-enrollment (OR 0.88). Implementation and completion of the program was cost neutral. This pilot supports team-based ambulatory care models that address the diverse needs of chronically ill patients, with a focus on improving select health services utilization.

Collaborative nurse-led self-management support for primary care patients with anxiety, depressive or somatic symptoms: Cluster-randomised controlled trial (findings of the SMADS study)

BackgroundCollaborative, nurse-led care is a well-established model of ambulatory care in many healthcare systems. Nurses play a key role in managing patients’ conditions as well as in enhancing symptom- and self-management skills. ObjectiveThe SMADS trial evaluated the effectiveness of a primary care-based, nurse-led, complex intervention to promote self-management in patients with anxiety, depressive or somatic symptoms. Change in self-efficacy 12 months post baseline was used as the primary outcome. DesignThe SMADS trial set up a two-arm, cluster randomised controlled trial in the city of Hamburg, a large metropolitan area in the North West of Germany. SettingWe randomly allocated participating primary care practices to either the intervention group (IG), implementing a nurse-led collaborative care model, or to the control group (CG), where patients with the above psychosomatic symptoms received routine treatment. ParticipantsPatients from 18 to 65 years of age, regularly consulting a participating primary care practice, scoring≥5 on the anxiety, depressive or somatic symptom scales of the Patient Health Questionnaire (PHQ-D), German version. MethodsA mixed model regression approach was used to analyse the outcome data. Analyses were based on the intention-to-treat population: All enrolled patients were analysed at their follow-up. Additionally, we reported results as effect sizes. The robustness of the results was investigated by performing an observed cases analysis. Results325 participants (IG N=134, CG N=191) from ten practices in each study arm consented to take part and completed a baseline assessment. The mean group difference (ITT-LOCF, IG vs. CG) in self-efficacy at the post baseline follow-up (median 406days) was 1.65 points (95% CI 0.50–2.8) in favour of IG (p=0.004). This amounts to a small Cohen’s d effect size of 0.33. An observed cases analysis (168 participants, IG=56, CG=105) resulted in a mean difference of 3.13 (95% CI 1.07–5.18, p=0.003) between the groups, amounting to a moderate effect size of d=0.51. ConclusionA complex, nurse-led intervention, implemented as a collaborative care model, increased perceived self-efficacy in patients with symptoms of anxiety, depression or somatisation compare to control patients. For the first time in the German healthcare system, the SMADS trial validated the belief that a nurse can successfully complement the work of a general practitioner – particularly in supporting self-management of patients with psychosomatic symptoms and their psychosocial needs.

Comparison of Inpatient and Outpatient Ankle Fracture Surgery

Category: Ankle Introduction/Purpose: One of the emerging trends in contemporary healthcare is the shift in surgical resources to the outpatient setting coupled with reductions in the inpatient length of stay. Through a multi-center retrospective review of surgically treated ankle fractures, we sought to determine whether the selection for outpatient surgery or inpatient admission was dependent upon specific patient demographics, associated medical co-morbidities, or surgeon practice management. Methods: A multi-center retrospective cohort study of 240 surgically treated ankle fractures over a two-year period was performed. Two tertiary care hospitals and their affiliated ambulatory surgery centers were included in the study. Patient selection criteria was based on CPT codes while exclusion criteria included pediatric patient, open trauma, pilon fracture, or history of prior ankle fracture. Patient age, presence of poly-trauma, medical co-morbidities (syncope, hypertension, diabetes, as well as coronary artery, pulmonary, renal or hepatic disease), and ordering of CT-scan were evaluated in the study. Surgeons were divided into three groups according to fellowship training: foot and ankle (Group 1), trauma (Group 2, and general / other (Group 3). There were 2 foot and ankle fellowship trained orthopedists, 5 trauma fellowship trained orthopedists, and 9 generalists whose fellowships included sports, hand, and spine. Results: 142 inpatient surgeries were performed with 5 days median length of stay and 98 surgeries were performed in the outpatient ambulatory care setting. The chi-square test or Fisher's exact test was used to compare inpatients and outpatients for each variable. Statistically significant higher percentages were recorded among inpatients in the following categories: age 65+ years (p < 0.0003), hypertension (p < 0.0230), presence of poly-trauma (p < 0.0149), and ordering of CT-scan (p < 0.0001). The majority of ankle fracture surgeries performed by Group 1 surgeons (84%) and Group 3 surgeons (61%) were outpatient cases compared with only 29% for Group 2 surgeons. There were no statistically significant differences in demographics and medical risk factors among patients in the three groups. Conclusion: Our data shows that age (65+ years-old) and specific medical co-morbidities are statistically linked with inpatient admission for ankle fracture surgery. In this multi-center review, trauma fellowship trained surgeons on-call were more likely to hospitalize their patients in preparation for surgery. With a 5 day median length of stay for these inpatient admissions, the health care institution may realize substantial practice management cost savings by shifting cases to the outpatient setting using the ambulatory care model of foot and ankle fellowship trained surgeons.

Infection Control for Drug-Resistant Tuberculosis: Early Diagnosis and Treatment Is the Key.

Multidrug-resistant (MDR) tuberculosis, "Ebola with wings," is a significant threat to tuberculosis control efforts. Previous prevailing views that resistance was mainly acquired through poor treatment led to decades of focus on drug-sensitive rather than drug-resistant (DR) tuberculosis, driven by the World Health Organization's directly observed therapy, short course strategy. The paradigm has shifted toward recognition that most DR tuberculosis is transmitted and that there is a need for increased efforts to control DR tuberculosis. Yet most people with DR tuberculosis are untested and untreated, driving transmission in the community and in health systems in high-burden settings. The risk of nosocomial transmission is high for patients and staff alike. Lowering transmission risk for MDR tuberculosis requires a combination approach centered on rapid identification of active tuberculosis disease and tuberculosis drug resistance, followed by rapid initiation of appropriate treatment and adherence support, complemented by universal tuberculosis infection control measures in healthcare facilities. It also requires a second paradigm shift, from the classic infection control hierarchy to a novel, decentralized approach across the continuum from early diagnosis and treatment to community awareness and support. A massive scale-up of rapid diagnosis and treatment is necessary to control the MDR tuberculosis epidemic. This will not be possible without intense efforts toward the implementation of decentralized, ambulatory models of care. Increasing political will and resources need to be accompanied by a paradigm shift. Instead of focusing on diagnosed cases, recognition that transmission is driven largely by undiagnosed, untreated cases, both in the community and in healthcare settings, is necessary. This article discusses this comprehensive approach, strategies available, and associated challenges.

Emergency department use among children with tracheostomies: Avoidable visits.

To characterize high emergency department (ED) use by children with tracheostomies and complex chronic conditions, to distinguish avoidable from unavoidable ED visits, and to describe the financial impact of avoidable visits. Children with tracheostomies in a pediatric tertiary care center with the highest ED utilization were identified via analysis of administrative data. Six experts in interdisciplinary dyads reviewed the records from all ED visits for these children, and distinguished avoidable from unavoidable visits. Hospital cost data for avoidable visits is described. Among 75 children with tracheostomies and complex chronic conditions, 23 (31%) were high ED utilizers. These 23 children accounted for 74% of all ED discharges the total group of 75 children from 2008 to 2011. Four of these 23 children with high utilization were excluded, leaving 19 subjects for review. These 19 children had 312 ED visits, of which 103 (33%) were deemed avoidable. Leading reasons for avoidable visits were uncomplicated upper respiratory infections, gastrointestinal infections, and enteral feeding system problems. Avoidable visits cost the hospital {$}67,940. One-third of ED visits by children with tracheostomies and complex chronic conditions may be avoidable. Increased ambulatory access to interdisciplinary teams of providers familiar with these children's unique needs might reduce avoidable ED visits and improve health outcomes. Further studies on how this model of ambulatory care might affect ED utilization and total healthcare costs are needed.

Relationship between health-related quality of life, comorbidities and acute health care utilisation, in adults with chronic conditions.

BackgroundThere is increased interest in developing multidisciplinary ambulatory care models of service delivery to manage patients with complex chronic diseases. These programs are expensive and given limited resources it is important that care is targeted effectively. One potential screening strategy is to identify individuals who report the greatest decrement in health related quality of life (HRQoL) and thus greater need. The aim of this study was to explore the relationship between HRQoL, comorbid conditions and acute health care utilisation.MethodsA prospective, longitudinal cohort design was used to evaluate the impact of HRQoL on acute care utilisation rates over three-years of follow-up. Participants were enrolled in chronic disease management programs run by a metropolitan health service in Australia. Baseline data was collected from 2007–2009 and follow-up data until 2012. Administrative data was used to classify patients’ primary reasons for enrolment, number of comorbidities (Charlson Score) and presentations to acute care. At enrolment, HRQoL was measured using the Assessment of Quality of Life (AQoL) instrument, for analysis AQoL scores were dichotomised at two standard deviations below the population norm.ResultsThere were 1999 participants (54 % male) with a mean age of 63 years (range 18–101), enrolled in the study. Participants’ primary health conditions at enrolment were: diabetes 915 (46 %), chronic respiratory disease 463 (23 %), cardiac disease 260 (13 %), peripheral vascular disease, and 181 (9 %) and aged care 180 (9 %). At 1-year multivariate logistic regression models demonstrated that AQOL utility score was not predictive of acute care presentations after adjusting for comorbidities. Over 3-years an AQoL utility score in the lowest quartile was predictive of both ED presentation (OR 1.58, 95 % CI, 1.16–2.13, p = 0.003) and admissions (OR 1.67, 95 % CI.1.21 to 2.30, p = 0.002) after adjusting for differences in age and comorbidities.ConclusionThis study found that both HRQoL and comorbidities were predictive of subsequent acute care attendance over 3-years of follow-up. At 1-year, comorbidities was a better predictor of acute care representation than HRQoL. To maximise benefits, programs should initially focus on medical disease management, but subsequently switch to strategies that enhance health independence and raise HRQoL.

Misclassification of OSA Severity With Automated Scoring of Home Sleep Recordings

The advent of home sleep testing has allowed for the development of an ambulatory care model for OSA that most health-care providers can easily deploy. Although automated algorithms that accompany home sleep monitors can identify and classify disordered breathing events, it is unclear whether manual scoring followed by expert review of home sleep recordings is of any value. Thus, this study examined the agreement between automated and manual scoring of home sleep recordings. Two type 3 monitors (ApneaLink Plus [ResMed] and Embletta [Embla Systems]) were examined in distinct study samples. Data from manual and automated scoring were available for 200 subjects. Two thresholds for oxygen desaturation (≥ 3% and ≥ 4%) were used to define disordered breathing events. Agreement between manual and automated scoring was examined using Pearson correlation coefficients and Bland-Altman analyses. Automated scoring consistently underscored disordered breathing events compared with manual scoring for both sleep monitors irrespective of whether a ≥ 3% or ≥ 4% oxygen desaturation threshold was used to define the apnea-hypopnea index (AHI). For the ApneaLink Plus monitor, Bland-Altman analyses revealed an average AHI difference between manual and automated scoring of 6.1 (95% CI, 4.9-7.3) and 4.6 (95% CI, 3.5-5.6) events/h for the ≥ 3% and ≥ 4% oxygen desaturation thresholds, respectively. Similarly for the Embletta monitor, the average difference between manual and automated scoring was 5.3 (95% CI, 3.2-7.3) and 8.4 (95% CI, 7.2-9.6) events/h, respectively. Although agreement between automated and manual scoring of home sleep recordings varies based on the device used, modest agreement was observed between the two approaches. However, manual review of home sleep test recordings can decrease the misclassification of OSA severity, particularly for those with mild disease. ClinicalTrials.gov; No.: NCT01503164; www.clinicaltrials.gov.

Child and Adolescent Psychiatry: Acceptance of a New Ambulatory Care System

To evaluate a new ambulatory care system in outpatient child and adolescent psychiatry based on the web-based Development and Well-Being Assessment (DAWBA). We analyzed patient paths (flows), acceptance, satisfaction, and staff costs in the newly implemented care model. The new model was very well accepted by the respondents (DAWBA response rate: 92 %). A third of the patients registered with the psychiatric service in 2012 were not in need of psychiatric treatment and were therefore referred to other psycho-social services. The additional staff costs of $ 200 per case might be low compared to the saved costs due to the avoidance of inappropriate medical care. The new ambulatory care model proved to be effective, efficient and broadly accepted when resources are strictly limited.