Ambulatory Health Care Centers Research Articles

Successful hepatitis B and C screening in the health check-up in the German primary care setting

Successful hepatitis B and C screening in the health check-up in the German primary care setting

Career prospects for ophthalmologists under 49years old : Asurvey in Germany from 2022

The need for care in ophthalmology is constantly increasing due to demographic changes. The study analyzed the current professional situation and future prospects of ophthalmologists under 49years old. The survey of members of the German Association of Ophthalmologists (Berufsverband der Augenärzte Deutschlands) and the German Ophthalmologic Society (Deutsche Ophthalmologische Gesellschaft) was conducted in 2022. All members under the age of 49years received an online questionnaire on the current professional situation as well as future perspectives (desired working hours, form of organization). The results of the survey were additionally compared with the 2016 survey of the German Association of Ophthalmologists. Asimilar questionnaire was used at that time. Atotal of 1014 people participated in the survey (62.7% women, mean age 39.3 ± 8years, 75.6% specialists). The response rate to the survey was 25%. Specialist practice from0 to 5years showed ahigher number of employed ophthalmologists (21% self-employed vs. 32% employed); over time the number of self-employed ophthalmologists increased (6-10years: 40%, > 10years: 59.3%). Overall, 46% of women were employed in apractice compared with 33% of men. Of the self-employed specialists, 95.9% said they planned to work in the same type of employment in 10years as currently. Regarding ophthalmologists' career future, the other employment types showed adesire to move to independent practice. Compared to the 2016 survey, gender differences related to the current type of employment were evident. The number of self-employed women decreased from 43% to 26% and self-employed men decreased from 63% to 39%. The number of ophthalmologists in ambulatory healthcare centers was doubled compared to 2016. Ophthalmologists reported similar future perspectives at both survey times. The results of the survey of ophthalmologists under 49years in Germany showed similar perceptions as in 2016. It became clear that the desire to be self-employed in 10years is very high; however, ophthalmologists expected large practices or medical care centers to prevail in the market. The number of self-employed doctors is decreasing and the desire for self-employment is difficult to realize.

Geographic, Occupational, and Sociodemographic Variations in Uptake of COVID-19 Booster Doses Among Fully Vaccinated US Adults, December 1, 2021, to January 10, 2022

COVID-19 booster vaccine can strengthen waning immunity and widen the range of immunity against new variants. To describe geographic, occupational, and sociodemographic variations in uptake of COVID-19 booster doses among fully vaccinated US adults. This cross-sectional survey study used data from the Household Pulse Survey conducted from December 1, 2021, to January 10, 2022. Household Pulse Survey is an online, probability-based survey conducted by the US Census Bureau and is designed to yield estimates nationally, by state, and across selected metropolitan areas. Receipt of a booster dose was defined as taking 2 or more doses of COVID-19 vaccines with the first one being the Johnson and Johnson (Janssen) vaccine, or taking 3 or more doses of any of the other COVID-19 vaccines. Weighted prevalence estimates (percentages) were computed overall and among subgroups. Adjusted prevalence ratios (APRs) were calculated in a multivariable Poisson regression model to explore correlates of receiving a booster dose among those fully vaccinated. A total of 135 821 adults completed the survey. Overall, 51.0% were female and 41.5% were aged 18 to 44 years (mean [SD] age, 48.07 [17.18] years). Of fully vaccinated adults, the percentage who reported being boosted was 48.5% (state-specific range, from 39.1% in Mississippi to 66.5% in Vermont). Nationally, the proportion of boosted adults was highest among non-Hispanic Asian individuals (54.1%); those aged 65 years or older (71.4%); those with a doctoral, professional, or master's degree (68.1%); those who were married with no children in the household (61.2%); those with annual household income of $200 000 or higher (69.3%); those enrolled in Medicare (70.9%); and those working in hospitals (60.5%) or in deathcare facilities (eg, funeral homes; 60.5%). Conversely, only one-third of those who ever received a diagnosis of COVID-19, were enrolled in Medicaid, working in pharmacies, with less than a high school education, and aged 18 to 24 years old were boosted. Multivariable analysis of pooled national data revealed that compared with those who did not work outside their home, the likelihood of being boosted was higher among adults working in hospitals (APR, 1.23; 95% CI, 1.17-1.30), ambulatory health care centers (APR, 1.16; 95% CI, 1.09-1.24), and social service settings (APR, 1.08; 95% CI, 1.01-1.15), whereas lower likelihood was seen among those working in food or beverage stores (APR, 0.85; 95% CI, 0.74-0.96) and the agriculture, forestry, fishing, or hunting industries (APR, 0.83; 95% CI, 0.72-0.97). These findings suggest continuing disparities in receipt of booster vaccine doses among US adults. Targeted efforts at populations with low uptake may be needed to improve booster vaccine coverage in the US.

\u201cAppropriateness and adequacy of antibiotic prescription for upper respiratory tract infections in ambulatory health care centers in Ecuador\u201d

BackgroundUpper respiratory tract infections are the leading cause of misuse of antibiotics, a problem that leads to unnecessary adverse events and antibiotic resistance. Antibiotic prescription in Ecuador was analyzed in order to evaluate the state of antibiotic prescribing for upper respiratory tract infections. Both the appropriateness and adequacy of prescribing was evaluated. Appropriateness represents the percentage of prescriptions that are indicated; adequacy refers to the percentage of patients requiring antibiotics who are treated.MethodsThe aim of the study is to analyze the appropriateness and adequacy of antibiotic prescription for upper respiratory tract infections in the Ambulatory Health Centers of the Ministry of Public Health of Ecuador. This is a cross-sectional study of patients from one Health Center of the Ministry of Public Health in the District 17D03 in Ecuador during 2015 with upper respiratory tract infection as a primary diagnosis.ResultsWe included a total of 1393 patients in the analysis. Out of the 1393 patients identified, 523 were prescribed antibiotics, constituting an antibiotic prescription rate of 37.5%, and 51 required antibiotics, reflecting a real need of antibiotics of 3.7%. Appropriateness: Of these 523 patients who were treated, 51 required an antibiotic, resulting in an appropriate antibiotic prescription rate of 9.75%. Adequacy: When analyzing each individual case, 33 of these 51 patients received an antibiotic, constituting an adequate prescription rate of 64.7%.ConclusionsThe results of our study report a 90.25% of inappropriate prescription. The antibiotic prescription, appropriate prescription, and adequate prescription rates show the need for implementation of strategies in order to reduce them. Related aspects regarding prescriber’s behavior and the patient’s expectations should be analyzed.

Updated strategies in the treatment of benign diseases—a patterns of care study of the german cooperative group on benign diseases

PurposeRadiation therapy (RT) is a common treatment for benign diseases in Germany. Because the treatment concepts are inconsistent, we conducted this pattern-of-care study on behalf of the German Cooperative Group on Benign Diseases to evaluate treatment standards in Germany. Methods and materialsQuestionnaires were mailed to all radiation therapy facilities in Germany. We assessed the treatment equipment, annual number of patients, treatment indications, and, in particular, treatment strategies in patients with benign diseases in 2014. ResultsWe evaluated questionnaires returned by 116 participating institutions, of which 41 were ambulatory health care centers, 28 were private institutions, 27 were community hospitals, and 20 were university hospitals. On average, 2 linac accelerators and 2 megavoltage units were available in each institution. In 2014, a total of 36,830 patients were treated for benign diseases: 16,989 for degenerative diseases (peritendinitis humeroscapularis n = 2691; epicondylitis humeri n = 3788; heel spur n = 10,510); 14,936 for osteoarthritis (coxarthrosis n = 2230; gonarthrosis n = 2623; omarthrosis n = 2691; rhizarthrosis n = 2440; polyarthrosis n = 2297; others n = 2655); 1563 for hyperproliferative diseases (morbus Dupuytren n = 960; morbus Ledderhose n = 441; keloids n = 139; pterygium of the conjunctiva n = 3; other hyperproliferative diseases n = 20); 2440 for functional disorders (gynecomastia n = 843; Graves' disease n = 205; lymphatic fistula n = 178; heterotopic ossification prophylaxis n = 1214); 859 for stereotactic RT in the central nervous system (arteriovenous malformation n = 53; meningioma n = 425; acoustic neuroma n = 201; pituitary adenoma n = 131; others n = 49), and 43 for rare indications (pigmented villonodular synovitis n = 20 or vertebral hemangioma n = 23). The mean whole dose was <10 Gy in the treatment of degenerative disorders, 25 Gy for hyperproliferative diseases, 15 Gy for functional disorders, and <50 Gy for stereotactic RT. ConclusionsIn 2014, RT had an important role in the treatment of benign diseases. Because treatment concepts are inherent, we recommend treatment based on the guidelines written by the German Cooperative Group on Benign Diseases.

Is liberal independent dental practice in danger? Assessing forms of dental practice in the European Regional Organization (ERO) zone of the FDI World Dental Federation.

A trend towards increasingly new forms of dental practice has been observed in the FDI World Dental Federation. Elementary foundations such as the free dentist and therapy choice, and independent, free, self-responsible professional practice may be undermined. The current study is aimed at analyzing the general training framework, organization, and professional types of dental practice in the European Regional Organization (ERO) zone and at critically discussing selected aspects of changes in the dental profession. A questionnaire was developed by the ERO Working-Group "Liberal Dental Practice." Information about dental schools, professional organizations, dental practice regulations, and ambulatory healthcare centers was analyzed. Self-employed dental practice is the most common type of practice (51.7%). Dentists are allowed to work independently immediately after graduation (72.7%). Approximately one-third are organized as compulsory members in chambers/corporations. The density of dentists has a mean of 1,570 inhabitants per dentist. In most countries, there are no special rules for founding dental ambulatory healthcare centers. In a total of 353 universities of the ERO countries surveyed, 16,619 dentists per year were trained, with a trend toward a higher percentage of female students (63%). Despite modern forms of dental practice, the charter of the individual liberal dental profession (CED et al, 2013) should be respected and taken into account on the basis of ethical principles. The commercialization of the dental profession can be neutralized only by establishing and following well-defined ethical principles; oral healthcare quality can thus be ensured without the influence of third parties.

The primary health care in the emirate of Abu Dhabi: are they aligned with the chronic care model elements?

BackgroundAbu Dhabi is the capital of the United Arab Emirates (UAE) and the largest of the seven emirates in terms of land mass and population. Abu Dhabi emirate has three different geographical regions: the Central Capital District, the Eastern Region, and the Western Region. The health system has been regulated by the Health Authority – Abu Dhabi (HAAD), and has been provided by the Abu Dhabi Health Services Company (SEHA), since 2007. The UAE has a high population-burden of morbidity and mortality related to chronic diseases. This paper aims to characterize the Primary Health Care (PHC) public services in Abu Dhabi using the Chronic Care Model (CCM) as a framework.MethodsOfficially published data from HAAD, SEHA and the UAE Ministry of Health and Prevention was reviewed and abstracted. The Preferred Reporting Items Systematic Reviews and Meta-Analysis (PRISMA) statement was used as a baseline to review the PHC services through the CCM approach and to identify potential opportunities for improvement.ResultsThere are 38 SEHA Ambulatory Healthcare Centers (AHS) that provide PHC, from which 20 are located in the Eastern Region and the other 18 in the Central Capital District. The AHS adopted the principles of the patient-centered medical home model, aiming at providing structured, proactive and coordinated care. Implementation of the CCM elements aligns with those standards and is positively associated with the use of interventions targeting high-risk behaviors.ConclusionThe UAE has a strong foundation in place for addressing the growing problem of chronic diseases. The CCM has been shown to have beneficial effects on clinical outcomes reinforcing the PHC procedures and processes of care and should continue to inform systematic efforts to improve the care that lead to better lives for the Abu Dhabi community.

German municipalities and their role in ensuring local primary health care

Introduction: Today, “physician shortage” is widely discussed in German media. In some rural areas the assurance of outpatient medical care, nearby home, is threatened due to developments on supply as well as on the demand side. The ageing population in Germany leads to rising needs for medical services. Further, the regional distribution of physicians and needs for medical services increasingly seems to diverge. Big cities are more attractive to physicians than most rural areas. In addition, the population in rural areas is older and thus has a rising demand for medical care.Smaller municipalities experience the problem of physician shortage in particular and are increasingly asked from local people to support local medical services with their own measures. However, by law they are not in charge of ensuring the supply of physicians. This is the task of the Associations of Statutory Health Insurance Physicians that plan and organize the distribution of physicians jointly with health insurance funds.Various experts confirm the growing relevance of outpatient health care as a local political issue on the municipal and county level. Competition between communities for young physicians is one option to support and improve local situations. This, however, could also lead to an increasing local mismatch.The aim of this study is to assess the political awareness of physician shortage on municipal level as well as to evaluate the implementation of local supporting measures in outpatient health care. Furthermore, we want to gather attitudes on a municipal level towards innovative models in outpatient health care.Methods: Mayors and county administrators were asked for the local government perspective on outpatient medical care through a postal survey. The survey was conducted in August 2015. The study sample consisted of all 412 professional mayors and 38 county administrators in the federal state Lower Saxony in North-Western Germany.The survey includes three chapters: 1. Assessment of current local physician supply (including availability and accessibility of doctors, vacancies in physicians’ offices); 2. Importance and influence of outpatient health care for municipalities (among others, the role of mayors); 3. Attitudes to innovative care models to support outpatient health care (nurse practitioners, patients’ buses, mobile physicians’ offices, telemedicine).Results: The response rate was 70.9 % for mayors and 81.6 % for county administrators.In every respondent municipality, there is at least one general practitioner. In 32.7 % of the municipalities, there is no further specialized physician. For 90.4 % of the respondents the outpatient care is an important location factor for their community. 71.3 % think the local disposability of general practitioners to be sufficient at the moment; 26.6 % of the participants claim a sufficient disposability of specialized physicians.A need of municipal support for outpatient physicians is stated by 68.2 %. However, 70.1 % remark on obstacles for implementation, predominantly the lack of responsibilities and money.Considering the attitudes to innovative care models, 70.4 % of respondent mayors support the use of nurse practitioners. 49.1 % vote for patients’ buses, 22.7 % for mobile physicians’ offices, and 12.5 % for telemedicine.Conclusion: Especially small villages in rural countys in Lower Saxony state increasing problems to replace retiring physicians. Disposability of and access to specialized physicians seems to be a bigger problem for municipal leaders, compared to accessibility of general practitioners. For most mayors and county administrators, ensuring local health supply is an essential element for an attractive local infrastructure. Therefore, many municipalities consider various options to attract physicians or have already realized actions of support.The supporting model with nurse practitioners is highly favored by municipal leaders. In contrast, telemedicine models, especially models encompassing remote treatment, are predominantly declined. Models to improve patients’ mobility get mixed reactions: While patients’ buses might help in rural regions with relatively bad short-range transport, mobile physicians’ offices are predominantly seen as too unattractive for physicians as well as too expensive for the health care system.Ensuring and further developing outpatient health care is a topic of growing relevance for German municipalities. The survey’s unusual high response rate emphasizes the importance of the issue. Historically, municipalities have little responsibilities in the sector of outpatient care. However, according to a new federal law, municipalities are assigned new possibilities to act in outpatient care by employing physicians in public ambulatory healthcare centers. Whether local authorities should get more involved in planning and organizing physicians supply, is still discussed.

Updated Strategies in the Treatment of Benign Diseases—A Patterns of Care Study of the German Cooperative Group on Benign Diseases

Abstract Purpose Radiation therapy (RT) is a common treatment for benign diseases in Germany. Because the treatment concepts are inconsistent, we conducted this pattern-of-care study on behalf of the German Cooperative Group on Benign Diseases to evaluate treatment standards in Germany. Methods and materials Questionnaires were mailed to all radiation therapy facilities in Germany. We assessed the treatment equipment, annual number of patients, treatment indications, and, in particular, treatment strategies in patients with benign diseases in 2014. Results We evaluated questionnaires returned by 116 participating institutions, of which 41 were ambulatory health care centers, 28 were private institutions, 27 were community hospitals, and 20 were university hospitals. On average, 2 linac accelerators and 2 megavoltage units were available in each institution. In 2014, a total of 36,830 patients were treated for benign diseases: 16,989 for degenerative diseases (peritendinitis humeroscapularis n = 2691; epicondylitis humeri n = 3788; heel spur n = 10,510); 14,936 for osteoarthritis (coxarthrosis n = 2230; gonarthrosis n = 2623; omarthrosis n = 2691; rhizarthrosis n = 2440; polyarthrosis n = 2297; others n = 2655); 1563 for hyperproliferative diseases (morbus Dupuytren n = 960; morbus Ledderhose n = 441; keloids n = 139; pterygium of the conjunctiva n = 3; other hyperproliferative diseases n = 20); 2440 for functional disorders (gynecomastia n = 843; Graves' disease n = 205; lymphatic fistula n = 178; heterotopic ossification prophylaxis n = 1214); 859 for stereotactic RT in the central nervous system (arteriovenous malformation n = 53; meningioma n = 425; acoustic neuroma n = 201; pituitary adenoma n = 131; others n = 49), and 43 for rare indications (pigmented villonodular synovitis n = 20 or vertebral hemangioma n = 23). The mean whole dose was Conclusions In 2014, RT had an important role in the treatment of benign diseases. Because treatment concepts are inherent, we recommend treatment based on the guidelines written by the German Cooperative Group on Benign Diseases.

Perceptions of Teamwork Following TeamSTEPPS Implementation at Ambulatory Reproductive Healthcare Facilities [3G

INTRODUCTION: TeamSTEPPS is an evidence-based teamwork system for healthcare professionals designed to improve patient safety. While team training has proven benefits in the hospital setting, it has not been well-studied in the ambulatory care environment. The objective of this project is to evaluate the impact of TeamSTEPPS in a network of ambulatory reproductive healthcare centers in the United States. METHODS: The Teamwork Perceptions Questionnaire (TPQ), a validated self-administered survey containing five domains of seven items each, was used to assess staff perceptions of teamwork within ambulatory reproductive healthcare centers. Unique participant codes linked responses at each time point. Comparisons were made between baseline and six-month assessments using paired t tests. RESULTS: Fifty-seven pairs of surveys were obtained from seven centers. Six of the seven items in the Team Structure, Situation Monitoring, and Mutual Support domains showed improvement, though only four were statistically significant (all P≤.03). Six items in the Leadership domain showed worse scores at six months, and four were statistically significant (all P≤.01). In the Communication domain, five items showed improved scores, though none was statistically significant. CONCLUSION: Six months after implementing TeamSTEPPS, improvements were seen in all domains with the exception of Leadership, though only eight items showed statistically significant change. Worsening perceptions of leadership may be due to increased awareness of best practices or indicate improvements in leadership are difficult. This short observation period may be inadequate to measure the extent of change from the TeamSTEPPS program. One-year assessments, as well as assessments of additional centers, are underway.

Determinants of diabetes and hypertension control in ambulatory healthcare in Al ain, United arab emirates.

This study aims to study determinants for the control of diabetes and hypertension in Al Ain Ambulatory Healthcare patients. This is a cross sectional observational study of patients attending ambulatory healthcare centers in Al Ain, United Arab Emirates in 2009. From a yearly audit evaluating the care of patients with diabetes and hypertension, the determinants for improved diabetes and hypertension outcomes were identified from a total of 512 patients and its association with glycemic and blood pressure control were studied. From all variables studied, only the clinic where the patient was treated helped predict both improved blood sugar and blood pressure control. For patients with diabetes, poor control the year before (p<0.001), the number of chronic disease clinic visits (p=0.042) and triglyceride levels (p=0.007) predicted worse control of diabetes. A predictor of poor control of blood pressure (p<0.001) for patients with hypertension was poor control of blood pressure in the year before. In this population, the healthcare system and the team played major roles as determinants in the control of patient's diabetes and blood pressure more than any of the other factors examined.

Increased oxidative damage in the plasma of adult type 2 diabetics with poor glycemic control (693.7)

Increased oxidative damage in the plasma of adult Type 2 diabetics with poor glycemic control Increasing evidence associates oxidative stress with the pathogenesis of Type 2 Diabetes (T2DM). Nonetheless, the available data related to oxidative stress and its relationships with glycemic status among T2DM patients are scarce and contradictory.Our goal was to investigate the relationships of metabolic control of T2DM with oxidative damage and antioxidant status.T2DM Emirati adults (n=187), participating in the Skills for Change randomized intervention trial and recruited from seven different ambulatory health care centers in Al Ain, United Arab Emirates, were considered. 24 h‐recall was collected. Anthropometry and HbA1c were assessed. Aantioxidant status markers were measured: Vitamin C, ABTS, Ferric Reducing Ability of Plasma (FRAP) and Glutathione (GSH). After stratification on HbA1c and age, oxidative damage (Malonaldehyde (MDA), protein carbonyls) were assessed in a sub‐sample (n=47).Means ± s.d. or percentages were calculated as appropriate. General linear model was used with adjustment for age, body mass index, food groups’ consumption (fruits, vegetables meat/beans, dairy), fat and total daily energy intakes.In the whole sample, mean age was 53.46±9.36 years, mean HbA1c was 7.69±1.54 %. A majority (86.50%) of patients was taking oral medication. Mean values for vitamin C, ABTS, FRAP and GSH were 0.09±0.07 g/L, 0.10±0.04 g /L, 1.00±0.46 g/L and 0.13±0.03 g/L, respectively. In the sub‐sample, MDA and protein carbonyls were 12.67±3.44 µmol/L and 0.29 nmol/L, respectively. None of the markers of antioxidant status were significantly related to HbA1c. MDA and protein carbonyls were strongly positively associated with HbA1c (p=0.02, 0.01, respectively).In this work, poor glycemic control is strongly positively associated with oxidative damage in adults with T2DM, suggesting that oxidative stress is closely intertwined with this disease.Grant Funding Source: Supported by Sheikh Hamdan Award

Demografischer Wandel

The growing absolute number of the elderly causes an increase in the number of patients suffering from not only chronic diseases and multimorbidity, but also higher usage of the health care system. In the German Federal State of Mecklenburg-Western Pomerania (MW), the effects of demographic change will be more pronounced than in other regions. The objective of this article is to show the consequences of the changing population structure for the health care system. Using examples from MW, innovative models to secure high quality health care at the population level are presented. Examples include the establishment of subsidiary practices, multidisciplinary ambulatory health care centers, delegation models, ambulatory health care managers, telemedicine, and intensified and improved interdisciplinary networking. In the context of the demographic change, assisted care, adequate symptom control, maintaining personnel competence, preservation of an independent lifestyle with a high quality of life, and stimulation of social participation become priority objectives of medical care. Besides the effectiveness and the quality of results with regard to these objectives, innovative health care models should be economically evaluated at the population level under real life practice conditions.

Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial.

Screening reduces colorectal cancer mortality, but effective screening tests remain underused. Systematic reminders to patients and physicians could increase screening rates We conducted a randomized controlled trial of patient and physician reminders in 11 ambulatory health care centers. Participants included 21 860 patients aged 50 to 80 years who were overdue for colorectal cancer screening and 110 primary care physicians. Patients were randomly assigned to receive mailings containing an educational pamphlet, fecal occult blood test kit, and instructions for direct scheduling of flexible sigmoidoscopy or colonoscopy. Physicians were randomly assigned to receive electronic reminders during office visits with patients overdue for screening. The primary outcome was receipt of fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy over 15 months, and the secondary outcome was detection of colorectal adenomas. Screening rates were higher for patients who received mailings compared with those who did not (44.0% vs 38.1%; P < .001). The effect increased with age: +3.7% for ages 50 to 59 years; +7.3% for ages 60 to 69 years; and +10.1% for ages 70 to 80 years (P = .01 for trend). Screening rates were similar among patients of physicians receiving electronic reminders and the control group (41.9% vs 40.2%; P = .47). However, electronic reminders tended to increase screening rates among patients with 3 or more primary care visits (59.5% vs 52.7%; P = .07). Detection of adenomas tended to increase with patient mailings (5.7% vs 5.2%; P = .10) and physician reminders (6.0% vs 4.9%; P = .09). Mailed reminders to patients are an effective tool to promote colorectal cancer screening, and electronic reminders to physicians may increase screening among adults who have more frequent primary care visits.

Managing quality in corporate ambulatory health care centers: the Southern California Edison story.

Managing quality in corporate ambulatory health care centers: the Southern California Edison story.

Emergency-room Services for a Community Health Center

The development and maintenance of an organized system of emergency care in isolated ambulatory health-care centers are described. A system of three community health centers, staffed chiefly by midlevel practitioners (i.e., physician's associates and nurse practitioners), had a need to provide occasional emergency care to patients. Emergency care needed to be provided (for up to one hour) until an ambulance arrived to transport the patient to a hospital. A system of emergency care, consisting of treatment protocols, a drug manual, equipment and medications, and a program for periodic inservice education was developed by physicians, midlevel practitioners, and pharmacists. Weekly checks of the supplies and medications are conducted. Lists of supplies and medications stocked, and a sample drug monograph, are included in the paper. The program has resulted in more efficient emergency care, including less confusion in executing and documenting treatment.

Moving toward the 21st century

The status of pharmacist education, areas of professional responsibility, pharmacy management, and ASHP membership is predicted for the coming decades. Because of changes in practice and greater use of nonpharmacists, colleges of pharmacy will graduate fewer pharmacists, all with Pharm.D.degree. Ph.D.-level programs will be initiated for specialized practice as institutional pharmacy continues to expand to include both total-service and specialized practitioners. Pharmacy management will become more demanding and, in large departments, may require both a professional and a nonprofessional director. Hospitals will become larger but fewer in number. They will serve large geographic areas, with the patients coming as referrals from ambulatory health care centers operating in smaller communities. With present services and programs, ASHP membership probably will level off at 21,000. If the Society can broaden its role, membership could reach 25,000--40,000, including many supportive personnel members. The formation of more specialty organizations may be necessary, but they will require a successful umbrella organization for the cooperation needed for continued growth of the profession.

An Approach to Reducing the Adverse Effects of Broken Appointments in Primary Care Systems

A method is presented for adjusting the scheduling of appointments in ambulatory health care centers to reduce the deleterious effects of broken appointments. The essence of the methodology calls for scheduling and "expected number" of patients for a given clinic session. This "expected number" is calculated from estimated probabilities of appointment breaking, conditioned on patient characteristics which are deemed to be related to appointment-breaking rates, and on which number appointment within a specified time period is being made for the patient. The two ill effects of appointment breaking that are considered here are the diminution of efficiency of operation and interference with continuity of patient care. Ways of using this methodology to ameliorate each of these effects are outlined, with one of these way serving to alleviate both effects. This method is meant to be of quite general applicability, although its development was motivated by the problems of a localized particular situation.

Time study of doctors and nurses at two Swedish health care centers: Swedish health center doctors and nurses.

The activities of six general practitioners, four office nurses, and a nurse specially trained in the care of diabetic patients as part of an experiment in medical care were studied in two Swedish ambulatory health care centers using time-motion methods. The doctors averaged 45.7 per cent of their time with patients, 28.7 per cent in indirect patient care activities, and 25.6 per cent in other activities. These averages are identical to those obtained from a study of a group of eight Oregon general practitioners in a previous study. The organization of personnel was different at the two health centers, as determined by factors of patient load and personnel experience. A nurse trained in chronic care of diabetics at one of the centers spent an average of 50.4 minutes per patient visit as opposed to 15.9 minutes per visit spent by doctors at the other center. The study has implications for the rational design of ambulatory care systems of good quality with high efficiency.