Hospital-based Outpatient Care Research Articles

Implementation outcomes of a digital, trauma-informed care, educational intervention targeting health professionals in a paediatric burns setting: A mixed methods process evaluation

Trauma-informed care practices are associated with a culture of safety following traumatic experiences, including medical trauma. An interactive, web-based training package (‘Responsive CARE’) was developed for voluntary uptake by paediatric burns health professionals to increase staff knowledge about trauma-informed practice. This paper reports on a mixed methods process evaluation conducted alongside a preliminary effectiveness study of ‘Responsive CARE’. The process evaluation was conducted using The Consolidated Framework for Implementation Research (CFIR) and a logic model, to examine feasibility of both the intervention and implementation strategy. Health practitioners (including senior managers) delivering care to children and caregivers attending an outpatient burns service were eligible to enrol in ‘Responsive CARE’. Qualitative interview data and quantitative metadata were used to evaluate the implementation outcomes (adoption, acceptability, fidelity, feasibility and preliminary effectiveness). Children and caregivers attending an outpatient service for change of burn wound dressing or burn scar management during the 3-month control or 3-month intervention period were eligible to enrol in the effectiveness study. The impact on child pain and distress, as well as cost, was investigated using a pretest-posttest design. Thirteen (from anticipated 50 enrolled) health professionals (all female) with mean 10 years (SD=11) of experience with paediatric burns hospital-based outpatient care completed an average of 65% (range 36% to 88%) of available content. Twenty-five semi-structured interviews were completed with health practitioners (21 female) and with 14 caregivers (11 female). Four themes were identified as influencing feasibility and acceptability of the intervention: 1) Keeping a trauma-informed lens; 2) Ways of incorporating trauma-informed care; 3) Working within system constraints; and 4) Being trauma-informed. Preliminary effectiveness data included 177 participants (median age 2 years, and median total body surface area burn 1%). Causal assumptions within the logic model were unable to be fully tested, secondary to lower-than-expected adoption and fidelity. We found no significant difference for pain, distress and per-patient hospital care costs between groups (pre- and post-intervention). Future implementation strategies should include organizational support to keep a trauma-informed lens and to incorporate trauma-informed principles within a medical model of care. Despite efforts to co-design a staff education intervention and implementation approach focused on stakeholder engagement, adaptations are indicated to both the intervention and implementation strategies to promote uptake highlighting the complexity of changing clinician behaviours.

The 'scan and treat' clinic; early evaluation of an advanced clinical practitioner (ACP) led combined echocardiography and outpatient cardiology clinic

Abstract Funding Acknowledgements Type of funding sources: None. Background There is increasing recognition that traditional models of hospital-based outpatient care in England are inefficient, unsustainable and do meet patient’s needs and preferences (RCP 2018). The National Health Service (NHS) ‘getting it right fist time’ (GIRFT) report for cardiology makes a number of recommendations including; increasing the utilisation non-medical roles such as Advanced Clinical Practitioners (ACPs), reducing face to face appointments, and triaging referrals with tests performed ahead of clinic appointments (NHS, 2021). We developed a novel clinic combining formal echocardiography with clinical assessment by a single British Society of Echocardiography (BSE) accredited ACP at medium sized district general hospital (DGH) in the west Midlands, England. No clinics of this type were identified in the literature, although there are studies demonstrating the efficacy of physiologist led valve clinics (Wasing et al., 2009) and cardiologist led ‘one stop’ clinics (Falces et al., 2008) Purpose To evaluate the case mix and early outcomes of the first 6 months of the scan and treat clinic. Methods Patient demographics, reason for referral and clinic actions were collected prospectively on an excel spreadsheet. A single un-blinded cardiologist reviewed the electronic patient records and echo images of 10 randomly selected patients from the first 3 months to assess the accuracy and appropriateness of documented diagnoses and treatment plans. Results 72 patients were seen over 11 clinics between July and December 2022. There was a low (6%) non-attendance rate, although a further 5 patients (7%) did not require an echo, due to booking errors. The most common reason for referral was suspected heart failure (33%) (table 1). Combined Heart Failure (HFrEF, HFmrEF, HFpEF) was also the most common primary diagnosis in the clinic (32%) (figure 1). There was a low rate of non-cardiac diagnoses (19%) and normal echocardiograms (33%) (figure 1). Clinic actions included prescribing (54%), cardiac monitors (24%), further imaging (15%) and blood tests (11%). The Cardiologist reviewer reported appropriate diagnosis and treatment of 10 radomly selected cases. Of 7 patients followed up in a cardiologist clinic before 10/01/2023, 5 had no significant changes in treatment or diagnosis, 1 patient had a pacemaker for asymptomatic 2nd degree AV block and another had Bisoprolol stopped due to side effects. Conclusion These preliminary results suggest the ‘scan and treat’ clinic is a viable alternative to traditional general cardiology clinic for patients who also require echocardiography. This review has a number of limitations including limited short term follow up, un-blinded cardiologist review and is not generalizable. This kind of initiative may help modernise and improve cardiology outpatient services. Further research is required to assess the efficacy of similar non-cardiologist led ‘one-stop’ clinic designs.Table 1Figure 1

Risk of Psychiatric Disorders Among Spouses of Patients With Cancer in Denmark and Sweden

There is emerging evidence that spouses of patients with cancer may have a higher prevalence of mental illness, but these studies have been limited by pre-post designs, focus on a single mental illness, and short follow-up periods. To assess the overall burden of psychiatric disorders among spouses of patients with cancer vs spouses of individuals without cancer and to describe possible changes in this burden over time. This population based cohort study included spouses of patients with cancer (diagnosed 1986-2016 in Denmark and 1973-2014 in Sweden; exposed group) and spouses of individuals without cancer (unexposed group). Members of the unexposed group were individually matched to individuals in the exposed group on the year of birth, sex, and country. Spouses with and without preexisting psychiatric morbidity were analyzed separately. Data analysis was performed between May 2021 and January 2022. Being spouse to a patient with cancer. The main outcome was a clinical diagnosis of psychiatric disorders through hospital-based inpatient or outpatient care. Flexible parametric models and Cox models were fitted to estimate hazard ratios (HRs) with 95% CIs, adjusted for sex, age and year at cohort entry, country, household income, and cancer history. Among 546 321 spouses in the exposed group and 2 731 574 in the unexposed group who had no preexisting psychiatry morbidity, 46.0% were male participants, with a median (IQR) age at cohort entry of 60 (51-68) years. During follow-up (median, 8.4 vs 7.6 years), the incidence rate of first-onset psychiatric disorders was 6.8 and 5.9 per 1000 person-years for the exposed and unexposed groups, respectively (37 830 spouses of patients with cancer [6.9%]; 153 607 of spouses of individuals without cancer [5.6%]). Risk of first-onset psychiatric disorders increased by 30% (adjusted HR, 1.30; 95% CI, 1.25-1.34) during the first year after cancer diagnosis, especially for depression (adjusted HR, 1.38; 95% CI, 1.30-1.47) and stress-related disorders (adjusted HR, 2.04; 95% CI, 1.88-2.22). Risk of first-onset psychiatric disorders increased by 14% (adjusted HR, 1.14; 95% CI, 1.13-1.16) during the entire follow-up, which was similar for substance abuse, depression, and stress-related disorders. The risk increase was more prominent among spouses of patients diagnosed with a cancer with poor prognosis (eg, pancreatic cancer: adjusted HR, 1.41; 95% CI, 1.32-1.51) or at an advanced stage (adjusted HR, 1.31; 95% CI, 1.26-1.36) and when the patient died during follow-up (adjusted HR, 1.29; 95% CI, 1.27-1.31). Among spouses with preexisting psychiatric morbidity, the risk of psychiatric disorders (first-onset or recurrent) increased by 23% during the entire follow-up (adjusted HR, 1.23; 95% CI, 1.20-1.25). In this cohort study of 2 populations in Denmark and Sweden, spouses of patients with cancer experienced increased risk of several psychiatric disorders that required hospital-based specialist care. Our results support the need for clinical awareness to prevent potential mental illness among the spouses of patients with cancer.

Health of singletons born after frozen embryo transfer until early adulthood: a Finnish register study.

Is the health of singletons born after frozen embryo transfer (FET) comparable to that of singletons born after fresh embryo transfer (ET) until early adulthood? The health of singletons born after FET does not differ from that of singletons born after fresh ET. The differences in perinatal outcomes of children born after FET and fresh ET are well known. FET is associated with an increased risk of large-for-gestational-age but diminished risks of preterm birth (PTB), small-for-gestational-age and decreased perinatal mortality compared to fresh ET. However, knowledge on the long-term health after FET is scarce. This retrospective register-based cohort study compares singletons born after FET (n = 1825) between the years 1995 and 2006 to those born after fresh ET (n = 2933) and natural conception (NC, n = 31 136) with a mean follow-up time of 18-20 years. Singletons born after FET were compared to those born after fresh ET and NC regarding the frequencies of diagnoses in the main ICD-10 chapters (International Statistical Classification of Diseases and Related Health Problems, 10th revision), the number of outpatient visits and hospital admissions, and mortality. Adjustments were made for PTB, maternal age, parity, socioeconomic status based on mother's occupation and offspring sex. The study combines data from the Finnish Medical Birth Register, the Finnish Care Register for Health Care (CRHC) and the Cause-of-Death Register at Statistics Finland. The Student's T-test was used for continuous variables, and the Chi-square test was used for categorical variables. Cox regression was used to estimate crude and adjusted hazard ratios (HRs and aHRs, respectively). A general linear model was used to compare the means of outpatient visits, hospital admissions and lengths of hospital stays per person. No significant differences between the FET and fresh ET groups were found in the frequency of diagnoses in any of the ICD-10 chapters or in the parameters describing the need for hospital care. However, compared to the NC group, higher proportions in the FET group had outpatient visits in the hospital (93.5% vs 92.2%, aHR 1.23, 95% CI 1.17, 1.30) or hospital admissions (48% vs 46.5%, aHR 1.28, 95% CI 1.19, 1.37). Compared to the NC group, the FET group had elevated adjusted risks of diagnoses of infectious and parasitic diseases (aHR 1.24; 95% CI 1.11, 1.38), neoplasms (aHR 1.68; 95% CI 1.48, 1.91), diseases of the eye and adnexa, the ear or mastoid process (aHR 1.11; 95% CI 1.01, 1.21), the respiratory system (aHR 1.15; 95% CI 1.06, 1.23), the digestive system (aHR 1.17; 95% CI 1.05, 1.32), the skin or subcutaneous tissue (aHR 1.28; 95% CI 1.14, 1.43) and the genitourinary system (aHR 1.27; 95% CI 1.11, 1.45), as well as congenital malformations or chromosomal abnormalities (aHR 1.31; 95% CI 1.14, 1.50) and symptoms, signs or abnormal clinical or laboratory findings (aHR 1.25, 95% CI 1.16, 1.34). Only hospital-based inpatient and outpatient care is covered by the CRHC register, excluding milder cases diagnosed elsewhere. We were not able to study the effect of ART treatments and subfertility separately in our setting. In addition, although our cohort is reasonably sized, even larger cohorts would be needed to reliably study rare outcomes, such as cancer. For many ICD-10 chapters, we present the first published data on the long-term outcome of singletons born after FET. The results on FET versus fresh ET are reassuring, whereas the results on FET versus NC warrant further investigation. Finnish government research funding was obtained for this study. Funding was also obtained from the Finnish Medical Society Duodecim, the Päivikki and Sakari Sohlberg Foundation, Orion Research Foundation, Finnish Society of Obstetrics and Gynaecology (research grants to A.M.T.) and Finnish government research funding. The funding sources were not involved in the planning or execution of the study. The authors have no competing interests to declare. N/A.

Implementing the Digital Diabetes Questionnaire as a Clinical Tool in Routine Diabetes Care: Focus Group Discussions With Patients and Health Care Professionals.

BackgroundThe Diabetes Questionnaire is a digital patient-reported outcome and experience measure for adults living with diabetes. The Diabetes Questionnaire is intended for use in routine clinical visits in diabetes care and to enable patient perspectives to be integrated into the Swedish National Diabetes Register. The Diabetes Questionnaire was developed on the basis of patients’ perspectives, and evidence for its measurement qualities has been demonstrated. Patients receive an invitation to complete the questionnaire before clinical visits, and the patient and health care professional (HCP) can discuss the findings, which are instantly displayed during the visit. Implementation processes for new tools in routine care need to be studied to understand the influence of contextual factors, the support needed, and how patients and HCPs experience clinical use.ObjectiveThe aim of this study was to describe patients’ and HCPs’ experiences of initiating the use of the digital Diabetes Questionnaire as a clinical tool in routine diabetes care, supported by a structured implementation strategy involving initial education, local facilitators, and regular follow-ups.MethodsIn this qualitative study, semistructured focus group discussions were conducted 12 months after the use of the Diabetes Questionnaire was initiated. Participants were diabetes specialist nurses and physicians (20 participants in 4 groups) at hospital-based outpatient clinics or primary health care clinics and adults with type 1 or type 2 diabetes (15 participants in 4 groups). The audiotaped transcripts were analyzed using inductive qualitative content analysis.ResultsThe results revealed 2 main categories that integrated patients’ and HCPs’ experiences, which together formed an overarching theme: While implementation demands new approaches, the Diabetes Questionnaire provides a broader perspective. The first main category (The Diabetes Questionnaire supports person-centered clinical visits) comprised comments expressing that the digital Diabetes Questionnaire can initiate and encourage reflection in preparation for clinical visits, bring important topics to light during clinical visits, and broaden the scope of discussion by providing additional information. The second main category (The process of initiating the implementation of the Diabetes Questionnaire) comprised comments that described differences in engagement among HCPs and their managers, challenges of establishing new routines, experiences of support during implementation, thoughts about the Diabetes Questionnaire, need to change local administrative routines, and opportunities and concerns for continued use.ConclusionsThe Diabetes Questionnaire can broaden the scope of health data in routine diabetes care. While implementation demands new approaches, patients and HCPs saw potential positive impacts of using the questionnaire at both the individual and group levels. Our results can inform further development of implementation strategies to support the clinical use of the questionnaire.

Application of Initial Function Training in Persistent Schizophrenia Patients Taking Aripiprazole

The natural efficacy based trials of the atypical antipsychotics are required to yield extensive information concerning the efficiency, security, tolerance and safety among the patients suffering from schizophrenia who are treated in the hospital-based outpatient care centre based practice. In this study, the men and women were taken with the age range of 14 to 90 y with recognition of schizophrenia. There were a total of 103 patients considered for this study, who were enrolled between July 2017 to August 2021. This study analyzed the treatment with aripiprazole along with the standard of care based treatment procedure. The patient data reviewed in this study during the screening process moved closer to an interactive voice response system after obtaining informed consent. In the aripiprazole treatment group (n=49), the results were significantly better and effective in comparison to the standard of care treatment group (n=54; p<0.001; w 26, last observation carried forward) as reflected by the interactive voice response system total score. Similar results were noted in patients who duly completed the study design where aripiprazole was significantly associated with effectiveness at all phases in comparison to the standard of care group. The patients treated with aripiprazole also showed a significantly higher increase in quality of life and lesser adverse effects at w 26 (p<0.001). A high percentage of patients who received aripiprazole as a study medication was termed as “much better’’ on the preference scale of the medication questionnaire in comparison to the standard of care. The schizophrenia trial of aripiprazole provides a detailed overview of the real-world rendering and the enhanced benefits of aripiprazole compared to other major atypical antipsychotics advised in the hospital.

Association Between Collagenous and Lymphocytic Colitis and Risk of Severe Coronavirus Disease 2019

Association Between Collagenous and Lymphocytic Colitis and Risk of Severe Coronavirus Disease 2019

Patients' perspectives on a new delivery model in primary care: A propensity score matched analysis of patient-reported outcomes in a Dutch cohort study.

Rationale, aims and objectivePrimary Care Plus (PC+) focuses on the substitution of hospital‐based medical care to the primary care setting without moving hospital facilities. The aim of this study was to examine whether population health and experience of care in PC+ could be maintained. Therefore, health‐related quality of life (HRQoL) and experienced quality of care from a patient perspective were compared between patients referred to PC+ and to hospital‐based outpatient care (HBOC).MethodsThis cohort study included patients from a Dutch region, visiting PC+ or HBOC between December 2014 and April 2018. With patient questionnaires (T0, T1 and T2), the HRQoL and experience of care were measured. One‐to‐two nearest neighbour calliper propensity score matching (PSM) was used to control for potential selection bias. Outcomes were compared using marginal linear models and Pearson chi‐square tests.ResultsOne thousand one hundred thirteen PC+ patients were matched to 606 HBOC patients with well‐balanced baseline characteristics (SMDs <0.1). Regarding HRQoL outcomes, no significant interaction terms between time and group were found (P > .05), indicating no difference in HRQoL development between the groups over time. Regarding experienced quality of care, no differences were found between PC+ and HBOC patients. Only travel time was significantly shorter in the HBOC group (P ≤ .001).ConclusionResults show equal effects on HRQoL outcomes over time between the groups. Regarding experienced quality of care, only differences in travel time were found. Taken as a whole, population health and quality of care were maintained with PC+ and future research should focus more on cost‐related outcomes.

Rosacea and perioral dermatitis: a single-center retrospective analysis of the clinical presentation of 1032 patients.

Rosacea is a common chronic inflammatory cutaneous disorder affecting nearly 5.5% of the adult population. Our aim was to evaluate the prevalence and epidemiology of rosacea and perioral dermatitis (POD) in an ambulatory care setting. We retrospectively analyzed medical data of patients with a confirmed diagnosis of rosacea or perioral dermatitis (POD) presenting at our university hospital outpatient clinic during a 3-year period. Out of 1032 patients, 81.5% were diagnosed with rosacea and 18.5% with POD. Overall prevalence was 1.4% for rosacea and 0.3% for POD. 69.3% of the analyzed patients were female. Overall mean age was 49.3±7.7 (1-92) years; the women's average age was less than the men's. Patients with POD were younger and predominantly female, whereas patients with phymatous rosacea were older and predominantly male. The most common phenotypes were papulopustular rosacea (68.4%), erythematotelangiectatic rosacea (22.5%), and phymatous rosacea (8.0%). Special forms of rosacea were diagnosed in 15.8% of the patients; the most frequent were ocular rosacea (6.9%) and steroid-induced rosacea (5.4%). The large patient cohort analyzed in our study provides a good estimate of the frequency of the rosacea subtypes, special forms and of perioral dermatitis in a hospital-based outpatient care setting.

PD29-04 EVOLUTION OF HEALTHCARE COSTS FOR LOWER URINARY TRACT SYMPTOMS ASSOCIATED WITH BENIGN PROSTATIC HYPERPLASIA

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Epidemiology & Evaluation (PD29)1 Apr 2020PD29-04 EVOLUTION OF HEALTHCARE COSTS FOR LOWER URINARY TRACT SYMPTOMS ASSOCIATED WITH BENIGN PROSTATIC HYPERPLASIA Charles Welliver*, Julia B. Ward, Lydia Feinstein, Kevin C. Abbott, Tamara Bavendam, Ziya Kirkali, Erline Martinez-Miller, Brian R. Matlaga, and Kevin McVary Charles Welliver*Charles Welliver* More articles by this author , Julia B. WardJulia B. Ward More articles by this author , Lydia FeinsteinLydia Feinstein More articles by this author , Kevin C. AbbottKevin C. Abbott More articles by this author , Tamara BavendamTamara Bavendam More articles by this author , Ziya KirkaliZiya Kirkali More articles by this author , Erline Martinez-MillerErline Martinez-Miller More articles by this author , Brian R. MatlagaBrian R. Matlaga More articles by this author , and Kevin McVaryKevin McVary More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000893.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Evolving management of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) has changed the distribution of healthcare spending. Our understanding of recent trends in LUTS/BPH management costs is incomplete given prior studies have been limited to older men, small datasets, and inpatient procedures. We characterized LUTS/BPH-related Medicare and private insurance expenditures over 10 years. METHODS: As part of the Urologic Diseases in America project, we analyzed two insurance claims databases: the Centers for Medicare & Medicaid Services Medicare 5% Sample for male Medicare beneficiaries aged ≥65 years with LUTS/BPH (N≈147,800 annually) and the Optum© de-identified Clinformatics® Data Mart Database (CDM) for privately insured males aged 40-64 years with LUTS/BPH (N≈100,300 annually). Annual LUTS/BPH-related expenditures from 2004-2013 were examined by service location: inpatient, hospital-based outpatient, and physician office. RESULTS: The average annual LUTS/BPH-related expenditures were $305 and $248 per LUTS/BPH patient in CDM and Medicare, respectively. Over the 10-year study period, inpatient care accounted for a decreasing percentage of total dollars spent on managing LUTS/BPH by Medicare (30% to 15%) and private insurance (37% to 15%). Outpatient LUTS/BPH-related expenditures rose for both insurer groups, especially for private insurance (61% to 83%). Expenditures for hospital-based outpatient care rose over the study period and exceeded physician office expenditures from 2007 onward for patients with private insurance, and from 2010 onward for Medicare patients (Figure). CONCLUSIONS: The distribution of healthcare expenditures for LUTS/BPH shifted across practice settings from 2004-2013, with increasing outpatient relative to inpatient expenditures. Hospital-based outpatient expenses exceeded physician office expenses, likely due to increased use of ambulatory surgical procedures for LUTS/BPH. In-office minimally invasive surgical therapies will likely lead to higher physician office costs in the future. Differences in expenditures between the study populations may be due to differential reimbursement practices between private insurance and Medicare. Source of Funding: Funded by the NIH via a contract to Social & Scientific Systems. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e619-e619 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Charles Welliver* More articles by this author Julia B. Ward More articles by this author Lydia Feinstein More articles by this author Kevin C. Abbott More articles by this author Tamara Bavendam More articles by this author Ziya Kirkali More articles by this author Erline Martinez-Miller More articles by this author Brian R. Matlaga More articles by this author Kevin McVary More articles by this author Expand All Advertisement PDF downloadLoading ...

A Case Study of an Effective and Sustainable Antiretroviral Therapy Program in Rural South Africa

The delivery of high-quality HIV care in rural settings is a global challenge. Despite the successful expansion of antiretroviral therapy (ART) in Africa, viral load (VL) monitoring and ART adherence are poor, especially in rural communities. This article describes a case study of an ART program in the deeply rural Eastern Cape of South Africa. The Zithulele ART Program initiated five innovations over time: (1) establishing district hospital as the logistical hub for all ART care in a rural district, (2) primary care clinic delivery of prepackaged ART and chronic medications for people living with HIV (PLH), (3) establishing central record keeping, (4) incentivizing VL monitoring, and (5) providing hospital-based outpatient care for complex cases. Using a pharmacy database, on-time VL monitoring and viral suppression were evaluated for 882 PLH initiating ART in the Zithulele catchment area in 2013. Among PLH initiating ART, 12.5% (n = 110) were lost to follow-up, 7.7% (n = 68) transferred out of the region, 10.2% (n = 90) left the program and came back at a later date, and 4.0% (n = 35) died. Of the on-treatment population, 82.9% (n = 480/579) had VL testing within 7 months and 92.6% (n = 536/579) by 1 year. Viral suppression was achieved in 85.2% of those tested (n = 457/536), or 78.9% (n = 457/579) overall. The program's VL testing and suppression rates appear about twice as high as national data and data from other rural centers in South Africa, despite fewer resources than other programs. Simple system innovations can ensure high rates of VL testing and suppression, even in rural health facilities.

A cross-sectional study to evaluate diabetes management, control and complications in 1631 patients with type 2 diabetes mellitus in Vietnam (DiabCare Asia)

AimsTo assess diabetes care delivery and prevention of short- and long-term diabetes-related complications in patients with type 2 diabetes mellitus (T2DM) in Vietnam.MethodsDiabCare Asia is an observational, non-interventional, cross-sectional study of hospital-based outpatient care for patients diagnosed with T2DM.ResultsA total of 1631 patients (mean age 62.7 years; 58.9% female) participated in the study. The percentage of patients with HbA1c < 7.0% (< 53 mmol/mol) was 36.1% and mean (standard deviation) HbA1c was 7.9 ± 1.8% (63 ± 19 mmol/mol). The proportion of patients using insulin was 40%, at a mean total daily dose of 35.4 U. Apart from dyslipidemia (81.2%) and hypertension (78.4%), the most common diabetes-related complications were peripheral neuropathy (37.9%) and eye complications (39.5%). Current insulin therapy was associated with peripheral vascular disease (odds ratio [OR] = 2.28 [95% confidence interval (CI) 1.68; 3.09]) and eye complications (OR = 1.70 [95% CI 1.37; 2.11]).ConclusionIn this sample of patients with T2DM in Vietnam, the majority had poor glycemic and metabolic control. Concerted efforts are needed to optimize control and prevent complications in these patients. Trial registration: NCT02066766

Substituting hospital-based outpatient cardiology care: The impact on quality, health and costs.

BackgroundMany Western countries face the challenge of providing high-quality care while keeping the healthcare system accessible and affordable. In an attempt to deal with this challenge a new healthcare delivery model called primary care plus (PC+) was introduced in the Netherlands. Within the PC+ model, medical specialists perform consultations in a primary care setting. PC+ aims to support the general practitioners in gatekeeping and prevent unnecessary referrals to hospital care. The aim of this study was to examine the effects of a cardiology PC+ intervention on the Triple Aim outcomes, which were operationalized by patient-perceived quality of care, health-related quality of life (HRQoL) outcomes, and healthcare costs per patient.MethodsThis is a quantitative study with a longitudinal observational design. The study population consisted of patients, with non-acute and low-complexity cardiology-related health complaints, who were referred to the PC+ centre (intervention group) or hospital-based outpatient care (control group; care-as-usual). Patient-perceived quality of care and HRQoL (EQ-5D-5L, EQ-VAS and SF-12) were measured through questionnaires at three different time points. Healthcare costs per patient were obtained from administrative healthcare data and patients were followed for nine months. Chi-square tests, independent t-tests and multilevel linear models were used to analyse the data.ResultsThe patient-perceived quality of care was significantly higher within the intervention group for 26 out of 27 items. HRQoL outcomes did significantly increase in both groups (P <0.05) but there was no significant interaction between group and time. At baseline and also at three, six and nine months’ follow-up the healthcare costs per patient were significantly lower for patients in the intervention group (P<0.001).ConclusionsWhile this study showed no improvements on HRQoL outcomes, PC+ seemed to be promising as it results in improved quality of care as experienced by patients and lower healthcare costs per patient.

Hospital Prices Grew Substantially Faster Than Physician Prices For Hospital-Based Care In 2007-14.

Evidence suggests that growth in providers' prices drives growth in health care spending on the privately insured. However, existing work has not systematically differentiated between the growth rate of hospital prices and that of physician prices. We analyzed growth in both types of prices for inpatient and hospital-based outpatient services using actual negotiated prices paid by insurers. We found that in the period 2007-14 hospital prices grew substantially faster than physician prices. For inpatient care, hospital prices grew 42percent, while physician prices grew 18percent. Similarly, for hospital-based outpatient care, hospital prices grew 25percent, while physician prices grew 6percent. A majority of the growth in payments for inpatient and hospital-based outpatient care was driven by growth in hospital prices, not physician prices. Our work suggests that efforts to reduce health care spending should be primarily focused on addressing growth in hospital rather than physician prices. Policy makers should consider a range of options to address hospital price growth, including antitrust enforcement, administered pricing, the use of reference pricing, and incentivizing referring physicians to make more cost-efficient referrals.

Substituting hospital care with primary care: The evaluation of a cardiology Primary Care Plus intervention

Introduction: To deal with the pressures on the healthcare system, the healthcare system should focus on high-value health care by pursuing the three aims: improving the health of the population, improving the quality of care as experienced by patients and reducing the increase of healthcare costs. In the Netherlands, several initiatives focus on strengthening the primary care and substituting hospital care with primary care in order to keep the health care system sustainable. This study is concentrated on a cardiology primary care plus PC+ centre where cardiologists provide specialist consultations in a primary care setting. This PC+ intervention aims to improve the health of the population and patients’ experience of care while reducing the healthcare costs by decreasing the number of unnecessary referrals to specialist care in the hospital setting. Methods: This is a practice-based study with a longitudinal observational design. The study population consisted of adult patients with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre intervention group or hospital-based outpatient cardiology care control group. Data of the PC+ centre and the hospital were used to investigate the referral and follow-up patterns of intervention group patients compared to the control group. Furthermore, patients were asked to complete questionnaires at three different time points before consultation, directly after consultation, three months after consultation consisting of items about their demographics, health status SF-12, EQ-5D-5L and EQ-VAS and experience of care. Results: The data of the PC+ centre and the hospital consists of 1838 intervention patients and 2155 control patients. Preliminary results show that 27.9 % n= 513 of the intervention group was referred to hospital care after a consultation at the PC+ centre. Moreover, 437 intervention patients and 328 control patients were included in the questionnaire study. In 25 out of 27 items PC+ results in significantly higher levels of patient satisfaction compared to hospital-based outpatient care. The results of the EQ5D-5L indicate no differences in health status between the groups, taking into account the follow-up period of three months F=0.133; P=0.865. Discussion: PC+ is a new concept in the Dutch healthcare system and evidence about its effects is scarce. The findings of this study will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes. Conclusion: Whilethis study showed no effects on the health status of the patients, there are promising results looking at the patients’ experience of care and healthcare utilization. Lessons learned: The implementation, as well as the evaluation, of PC+ initiatives is a dynamic process which requires time and continuous interaction with the stakeholders. Limitations: This study does not yet provide insight in the actual effects of PC+ on healthcare costs. Suggestions for future research: Future research, concentrated on PC+, should continue focusing on the Triple Aim outcomes, with a particular focus on healthcare costs.

Patients' Experiences of Using a Cellular Photo Digital Breathalyzer for Treatment Purposes.

The field of eHealth systems is rapidly developing and is now expanding into alcohol treatment settings. Despite a growing public and professional interest, cellular photo digital breathalyzers (CPDBs) have not been investigated in a clinical context so far. In this study, we aimed to investigate the experiences of patients in alcohol treatment who had been using a CPDB-TripleA- for a minimum of three months. What are their personal experiences of using the CPDB? Do the patients think it supports them to change their drinking habits, and if so, in what way? A qualitative interview study with individuals who had been using the CPDB TripleA, for at least 3 months as complement to treatment (12-step program or hospital-based outpatient care). A thematic analysis with an inductive approach was used to identify, analyze, and interpret patterns within data. In all, 12 interviews were conducted with 8 men and 4 women. Participants were generally enthusiastic about the CPDB and found it convenient and useful, even though it created a need for privacy when using the device. Although technical problems were substantial, participants were tolerant to those. The system was perceived to support self-control and to restore relations, but did not replace the need for close contact with caregivers. Self-motivation to change drinking habits was essential, and could not be reached by solely using the CPDB. Participants perceived the CPDB as a convenient and useful tool that was supportive under the circumstances that it was used in a context that included personal contact with a caregiver; and the user felt more than just a minimum of motivation to reduce drinking. Technical stability needs to be achieved to secure long-term use.

Evaluating a cardiology Primary Care Plus intervention: a practice-based, mixed-methods research

Introduction: Health care delivery models should change to keep health care affordable, accessible and of high quality (1). In the Netherlands, a considerable number of reforms and interventions are focused on limiting volume growth of expensive hospital care by stimulating substitution of care (2, 3). This study focuses on a cardiology primary care plus (PC+) centre where cardiologists provide specialist consultations in a primary care setting. PC+ interventions intend to support GPs in gatekeeping and treating patients by intensifying and strengthening collaboration and communication between GPs and specialists. Additionally, PC+ aims to improve the health of the population and patients’ experience of care while reducing the health care costs by decreasing the number of (unnecessary) referrals to specialist care in the hospital setting (4). Aims: The objective of the study is to evaluate the effects of the cardiology PC+ centre on population health, experience of care and health care costs. Methods: The study is a practice-based, mixed-methods research involving a qualitative evaluation and a quantitative longitudinal observational study. The study population consists of adult patients with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre (intervention group) or hospital-based outpatient cardiology care (control group). All eligible patients will be asked to complete questionnaires at three different time points (before consultation, directly after consultation, three months after consultation) consisting of items about their demographics, health status (SF-12, EQ-5D-5L and EQ-VAS) and experience of care (based on the Consumer Quality Index). In addition, data will be collected about health care utilization and related medical spending. Results: Preliminary results are available. At the moment, 437 intervention patients and154 control patients are included. The results show no differences in health status between the groups on the EQ-VAS (F = 1.372; P = 0.242). In 25 out of 27 items the patient experience of care is rated significantly higher for PC+ compared to hospital care. The average grade for the patient experience on the provided care differs significantly between the groups (PC+ 9.04 ±0.945 vs. hospital care 7.89 ±1.025; P Discussion: Results suggest a positive effect of PC+ on care experiences. Insight into the appropriate patients group is needed for an efficient continuation of PC+. In the coming years, more insight is collected on the effects on health care utilization. During the conference the background, objectives, design and methods, and (preliminary) results of the study will be discussed in detail.

Evaluating a Dutch cardiology primary care plus intervention on the Triple Aim outcomes: study design of a practice-based quantitative and qualitative research

BackgroundIn an attempt to deal with the pressures on the health-care system and to guarantee sustainability, changes are needed. This study focuses on a cardiology primary care plus intervention. Primary care plus (PC+) is a new health-care delivery model focused on substitution of specialist care in the hospital setting with specialist care in the primary care setting. The intervention consists of a cardiology PC+ centre in which cardiologists, supported by other health-care professionals, provide consultations in a primary care setting. The PC+ centre aims to improve the health of the population and quality of care as experienced by patients, and reduce the number of referrals to hospital-based outpatient specialist care in order to reduce health-care costs. These aims reflect the Triple Aim principle. Hence, the objectives of the study are to evaluate the cardiology PC+ centre in terms of the Triple Aim outcomes and to evaluate the process of the introduction of PC+.Methods/DesignThe study is a practice-based, quantitative study with a longitudinal observational design, and an additional qualitative study to supplement, interpret and improve the quantitative study. The study population of the quantitative part will consist of adult patients (≥18 years) with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre (intervention group) or hospital-based outpatient cardiology care (control group). All eligible patients will be asked to complete questionnaires at three different time points consisting of questions about their demographics, health status and experience of care. Additionally, quantitative data will be collected about health-care utilization and related health-care costs at the PC+ centre and the hospital. The qualitative part, consisting of semi-structured interviews, focus groups, and observations, is designed to evaluate the process as well as to amplify, clarify and explain quantitative results.ConclusionsThis study will evaluate a cardiology PC+ centre using quantitative and supplementary qualitative methods. The findings of both sub-studies will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes.Trial registrationNTR6629 (Data registered: 25-08-2017) (registered retrospectively).

Healthcare costs in chronic kidney disease and renal replacement therapy: a population-based cohort study in Sweden

ObjectiveTo compare healthcare costs in chronic kidney disease (CKD) stage 4 or 5 not on dialysis (estimated glomerular filtration rate <30 mL/min/1.73m2), peritoneal dialysis, haemodialysis and in transplanted patients with...

The effect of complementary private health insurance on the use of health care services.

This study estimates the effect of complementary private health insurance (PHI) on the use of health care. The empirical analysis focuses on an institutional setting in which empirical findings are still limited; namely on PHI covering co-payment for treatments that are only partly financed by a universal health care system. The analysis is based on Danish data recently collected specifically for this purpose, which makes identification strategies assuming selection on observables only, and on both observables and unobservables also, both plausible and possible. We find evidence of a substantial positive and significant effect of complementary PHI on the use of prescription medicine and chiropractic care, a smaller but significant effect on dental care, weaker indications of effects for physiotherapy and general practice, and finally that the use of hospital-based outpatient care is largely unaffected. This implies that complementary PHI is generally not simply a marker of a higher propensity to use health care but induces additional use of some health care services over and above what would be used in the absence of such coverage.