Mean Visit Time Research Articles

“Dyading” in the Pediatric Clinic Improves Access to Care

This project evaluates the effect of "dyading" on pediatric outpatient care. In "dyading," the medical assistant (MA) works with the provider in the exam room during the chart review, history taking, and patient education. In sequential care, the patient interacts with the MA, then the provider, then the MA again, with waiting in between. The authors measured visit time (from the MA starting with patient to the end of visit), the mean number of patients seen in a clinic session per provider, and patient satisfaction. After implementation of "dyading," mean visit time decreased from 37 + or - 14 to 25 + or - 11 minutes, the mean number of visits/session increased from 8.24 to 9.25, and waiting in the exam room reported by families decreased from 77% to 46%. "Dyading" decreased visit time, which increased the number of patients seen, thereby improving access to care. Patient time in the exam room decreased, which freed up exam rooms.

Feeding visit time of fruit-eating birds in Cerrado plants: revisiting the predation risk model

Fruiting plants that attract frequent visits by fruit-eating birds tend to be predictable patches for a predator. Consequently, the risk of a predator attack increases the longer a bird stays on a fruiting plant. We tested whether large and cryptic species of fruit-eating birds spend more time per feeding visit than smaller and conspicuous ones in fruiting plants of the Brazilian Cerrado. Data were obtained from the literature for eight fruiting plant species and from field observations of birds feeding on fruits of Zanthoxylum rhoifolium (Rutaceae). We searched for a positive linear relationship between the mean visit time and the total length of the species, considering bird color as a covariate. Feeding visits of the large and cryptic bird species lasted longer than feeding visits of small and conspicuous species. Large birds may be safer from predators because large predators are less common. Cryptic birds may be difficult to be detected by predators and, consequently, may be less likely to be attacked by predators than conspicuous birds. Thus, our results provide support to the hypothesis that vulnerable bird species spend less time foraging in fruiting plants.

Use of patient flow analysis to improve patient visit efficiency by decreasing wait time in a primary care-based disease management programs for anticoagulation and chronic pain: a quality improvement study

BackgroundPatients with chronic conditions require frequent care visits. Problems can arise during several parts of the patient visit that decrease efficiency, making it difficult to effectively care for high volumes of patients. The purpose of the study is to test a method to improve patient visit efficiency.MethodsWe used Patient Flow Analysis to identify inefficiencies in the patient visit, suggest areas for improvement, and test the effectiveness of clinic interventions.ResultsAt baseline, the mean visit time for 93 anticoagulation clinic patient visits was 84 minutes (+/- 50 minutes) and the mean visit time for 25 chronic pain clinic patient visits was 65 minutes (+/- 21 minutes). Based on these data, we identified specific areas of inefficiency and developed interventions to decrease the mean time of the patient visit. After interventions, follow-up data found the mean visit time was reduced to 59 minutes (+/-25 minutes) for the anticoagulation clinic, a time decrease of 25 minutes (t-test 39%; p < 0.001). Mean visit time for the chronic pain clinic was reduced to 43 minutes (+/- 14 minutes) a time decrease of 22 minutes (t-test 34 %; p < 0.001).ConclusionPatient Flow Analysis is an effective technique to identify inefficiencies in the patient visit and efficiently collect patient flow data. Once inefficiencies are identified they can be improved through brief interventions.

Feasibility of Management of High-Grade Cervical Lesions in a Single Visit

The incidence of cervical cancer is higher among low-income and minority women who have never undergone a conventional Papanicolaou test or who do not follow up after testing. Screening has been shown to reduce cervical cancer incidence rates. To determine the feasibility and acceptability of immediately treating women with severely abnormal Papanicolaou test results by using a single-visit cervical cancer screening and treatment program and to compare treatment rates and 12-month follow-up rates with those of women who received usual care. Randomized controlled trial conducted among 3521 women aged 18 years or older recruited between January 1999 and April 2002 at US community health centers located in predominantly Latino underserved areas. Women randomized to usual care (n = 1805) were discharged immediately after examination. Women randomized to the single-visit group (n = 1716) remained at the clinic until the results of their conventional Papanicolaou test were available. Large loop electrosurgical excision procedure was performed in single-visit patients with either a diagnosis of a high-grade squamous intraepithelial lesion (HGSIL)/atypical glandular cells of undetermined significance (AGUS) or suspicion of carcinoma. All other patients with abnormal Papanicolaou test results were referred to abnormal cytology clinics or elected to receive follow-up care outside the study's medical system. Treatment rates for HGSIL/AGUS at 6 months, follow-up rates at 6 months for lower-grade lesions, and 1-year follow-up rates for all patients. The rate of abnormal Papanicolaou test results was 4.1%. One percent of results showed high-grade lesions. In the single-visit group, the mean visit time was 2.8 hours and the mean time for delivery and processing of the Papanicolaou tests was 66 minutes. Six months after randomization, 14 (88%) of 16 single-visit and 10 (53%) of 19 usual care patients with HGSIL/AGUS had completed treatment. Fifty percent in the single-visit program and 53% of usual care with less abnormal Papanicolaou tests completed treatment within 6 months. Overall, 36% in each group presented for a follow-up Papanicolaou test 1 year later. Women in the single-visit group with high-grade lesions (10/16; 63%) were significantly more likely to attend follow-up for Papanicolaou tests 12 months later than women with similar lesions in the usual care group (4/19; 21%). For cervical cancer screening, the single-visit program was feasible and the degree of acceptability was high in this underserved population. Single visit programs provide an opportunity to increase the rate of immediate treatment and follow-up of women with severely abnormal Papanicolaou test results. This strategy did not improve follow-up rates for women with less-abnormal results. Trial Registration http://ClinicalTrials.govIdentifier: NCT00237562.

Template-Guided Versus Undirected Written Medical Documentation: A Prospective, Randomized Trial in a Family Medicine Residency Clinic

To compare a template-driven medical documentation system to undirected handwritten documentation and determine whether the template (1) decreases physician evaluation time, (2) increases gross billing, and (3) increases physician satisfaction with the documentation process. A prospective randomized trial of documentation with a template system (T-System for Primary Care, Dallas, TX) versus undirected handwritten documentation was conducted in 2 separate teams of a single family medicine residency program. After training, one team used the template system and the other team used undirected written documentation. Clinic visit duration was recorded. Medical records were evaluated by a blinded professional coder to assign an evaluation/management code. Clinic visit duration and coding level differences were evaluated using an independent t test. At the conclusion of the study, residents completed a questionnaire to determine physician satisfaction with the documentation tool. Survey responses were on a -2 to + 2 Likert scale. Means and standard deviations are reported. A total of 1339 patients were included in the analysis of patient visits. There was no significant difference in clinic time between the template system and the written documentation visits. The mean visit time was 1.75 hours for both teams. For the analysis of gross billing, 1237 charts were included. The mean billing amount for written documentation was USD $150 and for the template system it was USD $163--a statistically significant difference. The physicians' surveys favored continuing to use the template documentation method. The template medical documentation system compared with undirected written documentation produced a significantly higher bill for the visit, yielding no differences in evaluation time, and was overall positively received by the residents and faculty.

ACCESSIBILITY TO PRIMARY HEALTH CARE CENTERS: EXPERIENCE AND EVALUATION OF AN APPOINTMENT SYSTEM PROGRAM

Appropriate access to health care is one of the components of Primary Health Care (PHC) and it can be a good quality indicator. We present in this paper the results of 1 year of follow-up of an appointment system applied in 29 PHC centers in the Balearic Islands, Spain; the program was set up by the National Institute of Health. Telephonic appointment proportion increased from the first weeks, stabilizing at about 70%. The number of calls that it is necessary to make in order to get an appointment at peak time is now 1.5 and only 1 throughout the rest of the day. To determine changes in the waiting time and visit time, and the user opinion of the system, an enquiry was made to a sample of patients 1 month before, and 1 month, 6 months and 1 year after the program started. The waiting time is now less than 15 min for most of the people interviewed, in contrast with the previous situation when the waiting time was more than 30 min. The visit time is longer now and more than two thirds of the people think that care is better or much better than prior to the start of the program. These results have been verified in the waiting room (11.2 min mean waiting time and 7.2 min mean visit time). We conclude that we have achieved the goals of the appointment system program in all the centers covered by our department.

Strong ergodicity for continuous-time, non-homogeneous Markov chains

Characterizations of strong ergodicity for Markov chains using mean visit times have been found by several authors (Huang and Isaacson (1977), Isaacson and Arnold (1978)). In this paper a characterization of uniform strong ergodicity for a continuous-time non-homogeneous Markov chain is given. This extends the characterization, using mean visit times, that was given by Isaacson and Arnold.

Strong ergodicity for continuous-time, non-homogeneous Markov chains

Characterizations of strong ergodicity for Markov chains using mean visit times have been found by several authors (Huang and Isaacson (1977), Isaacson and Arnold (1978)). In this paper a characterization of uniform strong ergodicity for a continuous-time non-homogeneous Markov chain is given. This extends the characterization, using mean visit times, that was given by Isaacson and Arnold.

Strong ergodicity for continuous-time Markov chains

The concept of strong ergodicity for discrete-time homogeneous Markov chains has been characterized in several ways (Dobrushin (1956), Lin (1975), Isaacson and Tweedie (1978)). In this paper the characterization using mean visit times (Huang and Isaacson (1977)) is extended to continuous-time Markov chains. From this it follows that for a certain subclass of continuous-time Markov chains, X(t), is strongly ergodic if and only if the associated embedded chain is Cesaro strongly ergodic.

Strong ergodicity for continuous-time Markov chains

The concept of strong ergodicity for discrete-time homogeneous Markov chains has been characterized in several ways (Dobrushin (1956), Lin (1975), Isaacson and Tweedie (1978)). In this paper the characterization using mean visit times (Huang and Isaacson (1977)) is extended to continuous-time Markov chains. From this it follows that for a certain subclass of continuous-time Markov chains, X(t), is strongly ergodic if and only if the associated embedded chain is Cesaro strongly ergodic.

Ergodicity Using Mean Visit Times

The finiteness of the mean visit time to state j is used in the characterization of uniform strong ergodicity for non-stationary Markov chains and weak ergodicity for stationary Markov chains. This clarifies a key difference between ergodicity and weak ergodicity for infinite stochastic matrices.