Outpatient Capacity Research Articles

DIFFERENCES BETWEEN INTERNAL VS OUTSOURCED WORKUPS FOR LUNG NODULES AT THE SOUTHEAST LOUISIANA VETERANS HEALTH CARE SYSTEM (SLVHCS) AFTER HURRICANE KATRINA

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: After Hurricane Katrina, the New Orleans VA no longer had the inpatient or outpatient capacity to facilitate the work-up of Veterans with new lung nodules. Consequently, work-ups between 2005 and 2015 were either performed by VA providers at a contracted hospital site (internal) or outsourced through non-VA providers in the community (external). We sought to compare whether there were any significant differences in time to diagnosis, initiation of treatment, and mortality between those worked-up “externally” vs “internally”. METHODS: Key data points were collected via retrospective chart review including patient demographics; medical co-morbidities; time from detection of lung nodule to pulmonary referral, pathologic diagnosis, and initiation of treatment; cancer stage at diagnosis; and overall survival. The patients were separated into two cohorts based on whether the diagnostic work-up was performed internally or externally. The mean time to diagnosis and treatment was compared between the two groups using a two-tailed T test. Differences in mortality was estimated by comparing the mean survival time between the two groups using a Tarone-Ware test. RESULTS: 518 Veterans between 2005 and 2015 were diagnosed with lung cancer in the SLVHCS. Of the 241 patients who met inclusion criteria, 195 underwent an internal work-up and 46 underwent an external work-up. Patients in the internal group were younger on average than the external group (65.0 vs 69.1 years, P =0.004). Average time to pathologic diagnosis was 49.6 days (SD 32.1 days) in the internal group and 58.7 days (SD 39.2 days) in the external group (P = 0.12). Average time to initiation of treatment was 89.8 days (SD 51.7 days) in the internal group and 107 days (SD 42.8 days) in the external group (P = 0.033). The incidence of patients with stage III or IV cancer at time of diagnosis was 63% in the internal group versus 35% in the external group (P = < 0.005). The mean survival time was 1039.0 days (SD 81.6 days) in the internal group and 1199.5 days (SD 120.0 days) in the external group (P = 0.007). CONCLUSIONS: There was a statistically significant shorter time to initiation of lung cancer treatment for Veterans worked-up within the VA system compared to those who were outsourced externally. There were no significant differences in the time from detection of lung nodule to time of pathologic diagnosis. Veterans who were worked-up externally had a statistically significant increased mean survival time, although this cohort was composed of patients with less advanced disease at time of diagnosis. CLINICAL IMPLICATIONS: Natural disasters, such as Hurricane Katrina, can have significant impacts on the VA healthcare system of that region. This can potentially lead to significant delays in care to Veterans residing in the affected area, and additional outside resources may be warranted to ensure timely and adequate access to care. DISCLOSURES: No relevant relationships by Corey Costantino, source=Web Response No relevant relationships by Karin Halvorson, source=Web Response No relevant relationships by Frederick Jung, source=Web Response

Contemporary Trends in Clinical Outcomes among Dialysis Patients with Medicare Coverage

Background: The dialysis patient population in the United States continues to grow. Trends in rates of death and hospitalization among dialysis patients have important consequences for outpatient dialysis capacity and Medicare spending. Objectives: To estimate contemporary trends in rates of death and hospitalization among dialysis patients in the United States, overall and within subgroups. Methods: We used Medicare Limited Data Sets (100% sample) in 2014–2017 to estimate trends in rates of death and hospitalization among dialysis patients with Medicare Parts A and B enrollment. We used seasonal autoregressive integrated moving average models to identify secular trends in the incidence of outcomes. Results: There were 631,075 unique patients; 222,924 deaths; and 1,876,779 hospital admissions. Weekly risks of both death and hospitalization exhibited strong seasonality. However, overall weekly risks of death were 34.9, 35.4, 35.2, and 35.7 deaths per 10,000 patients in 2014–2017, respectively (p = 0.47, from a likelihood ratio test of secular trend). The overall weekly risk of hospitalization was 3.08, 3.05, 3.11, and 3.11% in 2014, 2015, 2016, and 2017, respectively (p = 0.30). There were significant secular trends in risk of death in subgroups defined by black race and residency in South Atlantic states (p < 0.05). There were also secular trends in risk of hospitalization in subgroups defined by age 20–44 years, concurrent enrollment in Medicaid, and residency in South Central states. Conclusion: For the first time since the beginning of this century, rates of both death and hospitalization among dialysis patients with Medicare fee-for-service coverage have stagnated. The reasons for this change are unknown and require detailed assessment. Persistent lack of change in clinical outcomes may alter the future expectations about dialysis patient population growth.

A Multidisciplinary Transition Consult Service: Patient Referral Characteristics

PurposeChildren's hospitals must provide developmentally appropriate care to increasing numbers of young adults with complex healthcare needs as they transition to adult-oriented care. This article describes the patients, service, and short-term outcomes of an interprofessional healthcare transition (HCT) consult team comprised of nurses, social workers, a community health worker, and physicians. Design and methodsThe Adult Consult Team's tiered population framework stratifies patients by medical complexity. The team coordinates HCT services for patients with the highest complexity. Patients at least 18 years old are eligible if they have at least two specialists or an intellectual or developmental disability (IDD). Through a comprehensive medical and psychosocial assessment, the team prepares patients/families for adult-oriented healthcare. ResultsThe Adult Consult Team received 197 referrals from July 2017 to June 2018. Patients had at least two specialists (73%), IDD (71%), technology dependence (e.g., gastrostomy tube, 37%) and Medicaid insurance (57%). The team assisted patients seen in its outpatient clinic with navigating mental health services (39%), insurance issues (13%), IDD services (15%), and the guardianship process (37%) and creating comprehensive care plans. ConclusionsThe Adult Consult Team transferred 30 patients with medical complexity to adult primary and specialty care, significantly improving pediatric inpatient and outpatient capacity for pediatric-aged patients. A broad range of young adult medical, psychosocial, legal, educational, and vocational needs were addressed. Practice implicationsAn interprofessional team approach can help large pediatric healthcare systems address the multi-faceted needs of patients who are medically and psychosocially complex as they enter adulthood.

Amino Acid-Based Metabolic Profile Provides Functional Assessment and Prognostic Value for Heart Failure Outpatients.

Functional capacity is a crucial parameter correlated with outcomes. The currently used New York Heart Association functional classification (NYHA Fc) system has substantial limitations, leading to inaccurate classification. This study investigated whether amino acid-based assessment on metabolic status provides an objective way to assess functional capacity and prognosis in heart failure (HF) outpatients. Plasma concentrations of histidine, ornithine, and phenylalanine (HOP) were measured on 890 HF outpatients to assess metabolic status by calculating the HOP score. Cardiopulmonary exercise testing (CPET) was performed in 387 patients to measure metabolic equivalents (MET) in order to define the functional class based on MET (MET Fc). Patients were followed for composite events (death/HF-related rehospitalization) up to one year. We found only 47% concordance between the MET Fc and NYHA Fc. HOP scores worked better than NYHA Fc for discriminating patients with MET Fc II and III from those with MET Fc I, with the optimal cutoff value set at 8.8. HOP scores ≥ 8.8 were associated with risk factors for composite events in different kinds of HF populations and were a powerful predictor of composite events in univariate analysis. In multivariable analysis, HOP scores ≥ 8.8 remained a powerful event predictor, independent of other risk factors. Kaplan-Meier curves revealed that HOP scores of ≥8.8 stratified patients at higher risk of composite events in a variety of HF populations. In conclusion, amino acid-based assessment of metabolic status correlates with functional capacity in HF outpatients and provides prognostic value for a variety of HF populations.

An integrated approach to e-health, data collection and patient-reported outcomes in inflammatory bowel disease

Medical management of inflammatory bowel disease (IBD) is expensive and has a considerable side-effect profile. Nurse-led care must follow quality standards and relies on patient input and consistent monitoring. There are a variety of novel e-health solutions to assist with this. Data collection and audit participation can be streamlined with the implementation of a patient-management system linked with the IBD Registry national data-collection initiative. However, this can carry a burden of input for clinicians. Patient-reported outcome measures (PROMs) allow for patient self-efficacy and remote review, potentially increasing outpatient capacity and adding value to IBD services. PROMs need to be validated and easy to use, such as IBD-Control. An ecosystem approach is effective in a fractured e-health landscape, and PROMS should be integrated with accessible patient portals. It is hoped that these developments will increase monitoring opportunities and outpatient capacity, as well as help nurses manage the increasingly complex care prescribed for IBD patients.

Inverse association between mortality and estimated functional capacity in hypertensive male outpatients with established coronary artery disease

Exercise capacity has been inversely associated with the incidence and severity of hypertension and cardiovascular disease. Cardiopulmonary exercise testing (CPET) is the gold standard for the determination of exercise capacity (i.e. peak oxygen consumption [VO2peak]). However, CPET is not always readily available in clinical settings. A moderate 1-km treadmill walking test (1k-TWT) has been demonstrated to be a valid and simple tool for the assessment of exercise capacity in outpatients with cardiovascular disease. The aim of this study was to examine the association between VO2peak estimated during a 1k-TWT and all-cause mortality in patients with hypertension and stable coronary artery disease. A total of 597 patients aged 63 ± 9 years underwent the 1k-TWT, and were followed up for all-cause mortality. The 1k-TWT was individualized at a moderate perceptually-regulated exercise intensity (11-13 on the 6-20 Borg scale). Age, body mass index, heart rate, and time to complete the 1k-TWT were entered into the equations originally validated for VO2peak estimation. Subjects were stratified into quartiles according to baseline VO2peak, and mortality risks were calculated. During a median follow-up of 7.7 years, 79 deaths from any cause occurred, and resulted 36, 28, 10 and 5 for the first, second, third, and fourth quartile respectively. Compared to the lowest quartile (average VO2peak 18.1 ml/kg/min, n=149), the full-adjusted hazard ratios were 0.80 (p=0.49), 0.31 (p=0.02), and 0.13 (p=0.005) for the second (average VO2peak 21.8 ml/kg/min, n=150), third (average VO2peak 24.4 ml/kg/min, n=149), and fourth quartile (average VO2peak 28.7 ml/kg/min, n=149), respectively. VO2peak estimated by the 1k-TWT is a strong and independent predictor of all-cause mortality in patients with hypertension and coronary artery disease. Assessing VO2peak by the 1k-TWT can be a useful, simple and low-cost tool to stratify and follow up hypertensive patients with cardiovascular disease through cardiac rehabilitation and secondary prevention programs.

Is an advanced audiology-led service the solution to the paediatric ENT outpatient waiting list problem?

ABSTRACTPurpose: The present study's objective was to predict the effect of an advanced audiology-led clinic on paediatric ENT outpatient waiting lists in a large secondary public hospital.Methods: A retrospective, single observational study was performed to obtain data on all children referred for semi-urgent or routine ENT outpatient assessment over a six month period. Set criteria were used to calculate the proportion of new ENT referrals that could be eligible for a new advanced audiology-led clinic and the effect this could have on ENT outpatient referrals and capacity.Results: Results indicated that 23% of all semi-urgent and routine paediatric ENT outpatient referrals were eligible for referral to an advanced audiology-led clinic, with 74% of these being from the semi-urgent category. Based on these data, an advanced audiology-led clinic was predicted to increase this facility's ENT outpatient capacity by 77%.Conclusion: In conclusion, the introduction of an advanced audiology-led service could significantly reduce waiting lists and increase capacity in paediatric ENT outpatient services in the public healthcare system.

A comparison of fixed and variable capacity-addition policies for outpatient capacity allocation

Residents of mainland China always come to the first-class hospitals. Facing limitations to medical resources, hospital managers consider adding some potential capacity beyond the regular daily capacity to meet demands and improve the profit. This paper systematically studies the capacity-addition policy, and compares two kinds of them: fixed capacity-addition policy (F-CAP) and variable capacity-addition policy (V-CAP). The former sets the additional capacity by simple calculations according to experiences or history statistics. Under the V-CAP policy, the additional capacity is determined by solving an optimization model rather than a constant. The V-CAP definitely achieves the optimal expected profit, which can be regarded as the benchmark that leads to the best improvement. Since the F-CAP is widely used in many first-class hospitals in practice, this paper attempts to explore in which situations the F-CAP can achieve a similar improvement of the V-CAP, and in what environments the additional capacity should be a variable. In addition to focusing on additional capacity, both policies allocate the regular capacity to two types of patient: routine patients and same-day patients, who have different no-show probabilities. We formulate linear integer programming models of F-CAP and V-CAP to maximize the expected profit. Several propositions and corollaries are proved to cut off the solution space and accelerate the search process. The optimal additional capacity can be directly determined by these properties, and the optimal value is non-decreasing with the regular capacity allocated to routine patients. Numerical experiments indicate that the optimal total supply of regular capacity and additional capacity is always less than the expected total demand. The F-CAP is recommended to the environments with low no-show probabilities of routine patients and same-day patients, moderate expected total demand, correlation coefficient of demands and regular capacity, where the reduction of the expected profit is less than 5% of the F-CAP compared to the V-CAP.

Association of soluble ST2 with functional capacity in outpatients with heart failure

Biomarkers play an important role in the risk stratification of patients with heart failure (HF). Recent studies have shown that soluble suppression of tumorigenicity2 (sST2), a member of the interleukin1 receptor family, is associated with disease prognosis in acute and chronic HF. In this study we aimed to investigate the relation between sST2level and functional capacity in outpatients with systolic HF. This study included 120 HF patients with reduced ejection fraction (HFrEF; EF≤ 40%). The mean age of patients was 66± 11years. Advanced HF (New York Heart Association [NYHA] functional class III-IV) was observed in 35patients (29%). sST2levels were on average higher in patients with NYHA functional classes III and IV than in patients with NYHA functional classes I and II (51 [9-198] vs. 25 ng/ml [9-118], p< 0.001). In a multiple logistic regression model, sST2level (OR: 1.044, p= 0.004, 95% CI: 1.014-1.075), hemoglobin level (OR: 0.590, p= 0.001, 95% CI: 0.433-0.805), total cholesterol level (OR: 0.977, p= 0.004, 95% CI: 0.962-0.993), and age (OR: 1.066, p= 0.047, 95% CI: 1.001-1.136) were associated with poor functional capacity. In receiver operating characteristic (ROC) curve analysis, the optimal cut-off value of sST2 for predicting poor functional capacity was >42 ng/ml, with 63% sensitivity and 88% specificity (AUC: 0.810, 95% CI: 0.728- 0.875). Higher sST2levels were strongly associated with poor NYHA functional class, independent of cardiac risk factors, in outpatients with HFrEF.

Outpatient capacity allocation considering adding capacity to match high patient demand

This paper focuses on an outpatient capacity allocation problem where the patient demand is quite higher than the supply. We study an adding capacity policy to mitigate the mismatch between supply and demand. Under this policy, the doctor is allowed to add capacity if all regular capacity have been booked. A capacity allocation model is formulated for both possible no-show routine patients and all show-up same-day patients. The purpose is to determine the number of capacity can be added and how to allocate regular capacity among routine patients and same-day patients, towards maximizing the expected profit, which is composed of the expected income minus the cost of weighted expected doctor’s overload work caused by the adding capacity policy and the cost of rejecting patients. To achieve the aims, we prove the expected profit monotonously decreases when the number of additional capacity exceeds a threshold, and present a two-tier enumeration search algorithm to find the global optimal solution based on the proof. Numerical results indicate that the proposed policy performs well under different levels of demand higher than supply. The optimal number of the additional capacity is hardly affected by varying total expected patient demand. Additionally, under the change of no-show rate, the number of regular capacity allocated to routine patients becomes more stable, compared with the optimal scheme without considering adding capacity policy.

381 - Heart Failure Care Transitions: A Queuing Theory Approach to Quantify the Impact of Vacation Periods on Discharge Clinic Wait Times

Background: Heart failure (HF) readmissions remain a major driver of cost and health care utilization. Timely follow-up of patients post-discharge represents an evidence-based intervention proven to reduce readmission rates. A previously unexplored characteristic of hospital discharges is variability in follow-up availability owing to clinician vacations. This variability thwarts the timeliness of follow-up, negates the benefit of transitional care planning, and may lead to a higher risk of HF readmissions. Queuing theory is the mathematical study of waiting times. We opted to use queuing theory to analyze the impact of clinician vacation periods on clinic performance. Objective: To analyze the impact of clinician vacation periods on outpatient clinic capacity needs using HF hospitalization discharge data and operations management approaches. Methods: Higher risk hospitalizations requiring active transitional care heart failure management were detected using an electronic data warehouse-supported process over the study period. Queuing theory approaches were used to model the impact of HF discharge clinic capacity and clinician vacations on wait time to an appointment. Results: During the study period of 100 days, 566 HF discharges were made, for a median of 5.66 discharges daily, or 39.6 discharges weekly. The distribution of daily discharges was skewed rightward (mode = 3, range = 0 to 18, standard deviation = 3.3, coefficient of variation = 0.58). Current clinic design: Providing 40 discharge clinic appointments per week (99% utilization) leads to an average wait of 18.3 days prior to an appointment, with only 31.9% of appointments scheduled within 7 days. A clinician vacation reducing clinic capacity by 25% for 1 week takes 24 weeks for recovery. Clinic redesign using queuing theory: Providing five extra discharge appointment slots per week (88% utilization) reduces the expected waiting period to 1.1 days (versus 18.3), with 99.8% of patients seen within 7 days (versus 31.9%). In this scenario, recovery time to steady state after the 1 week vacation period is reduced from 24 weeks to 9 days. Conclusions: Deployment of queuing theory allows for a more precise quantification of clinical capacity needed to accomplish appropriate HF follow-up. Our simplified model demonstrates that, in the absence of a modest capacity buffer, variability in hospital discharge rates leads to both excessive clinic wait times and recovery times from vacation periods, consequently exposing patients to a higher risk of HF readmission. We show using single center HF discharge data that a 10–15% increase in capacity is needed to ensure an adequate follow-up service level. Ongoing process of care work will demonstrate if optimization of clinic load yields a significant reduction in HF readmissions.

IMPROVED QUALITY OF LIFE SCORES AND EXERCISE CAPACITY WITH REMOTE PULMONARY ARTERY PRESSURE MONITORING IN PATIENTS WITH CHRONIC HEART FAILURE

The impact of remote pulmonary artery pressure (PAP) monitoring on quality of life (QOL) and exercise capacity in outpatients with chronic heart failure is unknown. Sixty six outpatients with NYHA class III heart failure were screened for implantation of a PAP monitoring device, CardioMEMS (CM).

Abstract 161: Heart Failure Care Transitions: A Queuing Theory Approach to Match Variable Hospital Discharge Rate With Outpatient Clinic Capacity

Background: Heart failure (HF) readmissions remain a major driver of cost and health care utilization. Timely follow-up of patients post-discharge represents an evidence-based intervention proven to reduce readmission rates. A previously unexplored characteristic of hospital discharges is variability in discharge caseload. This variability thwarts the timeliness of follow-up, negates the benefit of transition care planning and may lead to a higher risk of HF readmissions. Queuing theory is the mathematical study of waiting times. We opted to use queuing theory to determine if caseload can be determined more precisely in a manner that sufficiently accommodates HF discharge variability. Objective: To analyze the impact of hospital discharge rate variability on outpatient clinic capacity needs using HF hospitalization discharge data and operations management approaches. Methods: Higher risk hospitalizations requiring active transitional care heart failure management were detected using an enterprise data warehouse-supported process over the study period. Queuing theory approaches were used to model the impact of HF discharge clinic capacity on wait time to an appointment. Discharge clinic was modeled as a single 7-day follow-up appointment, with an acceptable scheduling window of 5 to 9 days post-discharge. Results: During the study period of 100 days, 566 HF discharges were made, for a median of 5.66 discharges daily, or 39.6 discharges weekly. The distribution of daily discharges was skewed rightward (mode = 3, range = 0 to 18, standard deviation = 3.3, coefficient of variation = 0.58). Current clinic design: Providing one discharge slot for every hospital discharge (100% utilization) leads to an average wait of 18.3 days prior to an appointment, with only 31.9% of appointments scheduled within 7 days, and 38.9% of appointments scheduled within 9 days. Clinic re-design (queuing theory): Providing five extra discharge appointment slots per week (88% utilization or 13.6% excess capacity) reduces the expected waiting period to 1.1 days, with 99.8% of patients seen within 7 days, and virtually all patients seen within 9 days of discharge. Conclusions: Deployment of queuing theory allows for a more precise quantification of needed clinical capacity to accomplish appropriate HF follow-up with a reasonable degree of certainty. Our simplified model demonstrates that variability in hospital discharge rates leads to excessive clinic wait times in the absence of a modest capacity buffer and consequently exposes patients to a higher risk of HF readmission. We show using single center HF discharge data that a 10-15% increase in capacity is needed to ensure an adequate follow-up service level. Ongoing process of care work will demonstrate if optimization of clinic load yields a significant reduction in HF readmissions.

The Evolution of Teleophthalmology Programs in the United Kingdom: Beyond Diabetic Retinopathy Screening.

Modern ophthalmic practice in the United Kingdom is faced by the challenges of an aging population, increasing prevalence of systemic pathologies with ophthalmic manifestations, and emergent treatments that are revolutionary but dependent on timely monitoring and diagnosis. This represents a huge strain not only on diagnostic services but also outpatient management and surveillance capacity. There is an urgent need for newer means of managing this surge in demand and the socioeconomic burden it places on the health care system. Concurrently, there have been exponential increases in computing power, expansions in the strength and ubiquity of communications technologies, and developments in imaging capabilities. Advances in imaging have been not only in terms of resolution, but also in terms of anatomical coverage, allowing new inferences to be made. In spite of this, image analysis techniques are still currently superseded by expert ophthalmologist interpretation. Teleophthalmology is therefore currently perfectly placed to face this urgent and immediate challenge of provision of optimal and expert care to remote and multiple patients over widespread geographical areas. This article reviews teleophthalmology programs currently deployed in the United Kingdom, focusing on diabetic eye care but also discussing glaucoma, emergency eye care, and other retinal diseases. We examined current programs and levels of evidence for their utility, and explored the relationships between screening, teleophthalmology, disease detection, and monitoring before discussing aspects of health economics pertinent to diabetic eye care. The use of teleophthalmology presents an immense opportunity to manage the steadily increasing demand for eye care, but challenges remain in the delivery of practical, viable, and clinically proven solutions.

Respiratory muscle fatigue and functional capacity in heart failure: a randomized study

Aim: To compare the effect of inspiratory muscle and expiratory muscle fatigue on the functional capacity in outpatients with systolic heart failure. Method: a randomized, crossover study, controlled, double-blind, focusing on outpatients, from June 2014 to December 2015. Individuals will be allocated to a group that will perform 80% inspiratory and expiratory muscle effort (IME and EME) in terms of maximum airway pressure to induce fatigue, or 0% for the placebo (three sets of 10 repetitions). The order in terms of effort and load will be randomized. Before and after the respiratory muscle effort, capillary lactate testing and a six-minute walk test will be performed. Expected results: Specific training for respiratory muscles can improve the functional capacity and the prognosis of these patients with systolic heart failure .

Historically strong residential sites building major outpatient capacity

Alcoholism & Drug Abuse WeeklyVolume 27, Issue 33 p. 1-8 The Business of Treatment Historically strong residential sites building major outpatient capacity Gary Enos, Gary EnosSearch for more papers by this author Gary Enos, Gary EnosSearch for more papers by this author First published: 24 August 2015 https://doi.org/10.1002/adaw.30298Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume27, Issue3324 August 2015Pages 1-8 RelatedInformation

PTU-081 The impact of a nurse co-ordinated ibd multidisciplinary team meeting in enhancing safety and reducing cost

<h3>Introduction</h3> The management of biologic therapy in IBD poses many challenges to clinicians. The U. K. IBD Standards¹have highlighted the need for a structured approach to the view of patients, but this can prove difficult as a result of limitations in outpatient capacity. The gastroenterology team aimed to evaluate the impact of a multidisciplinary team (MDT) meeting on clinical outcome and cost efficiencies. <h3>Method</h3> A one hour weekly MDT meeting was established to review all in-patients with IBD and those receiving biologic therapy. In addition, clinicians discussed cases that required additional opinions in management. This was attended by Consultant gastroenterologists, IBD Nurse Specialists, dieticians, junior medical staff and consultant surgeon. Outcomes from the meeting where recorded on a database and prospectively audited. <h3>Results</h3> Within a 6 month period the IBD team meet on 22 occasions. 257 patients where reviewed (120 male, 137 female median age 36 (16–77) with IBD (210 Crohn’s disease, 39 ulcerative colitis and 3 pouchitis and 5 IBDU). Biological therapy was reviewed in 182 cases, including 136 patients requiring a routine annual review of therapy. Of the latter group, biological therapy was continued in 112/182 (61%) cases, based on continued disease activity. 18/182 (9%) patients where referred for further investigation to evaluate response to treatment and 6 where referred for outpatient clinic review. Clinical management was reviewed in 46 patients, and subsequently 18/46 patients had treatment de-escalated or ceased as a result of clinical improvement or mucosal healing. 8 patients with adverse events were reviewed and a further 8 patients had their biologic changed. 2 where referred for discussion at the medical surgical MDT. Endoscopy referrals where requested in 20 cases, MR scan in 7 cases and an urgent clinic appointment in 23 cases. A further 75 patients raised for general discussion regarding clinical management. 10 were in-patients, and 3 were referred for surgical review, a further 7 had treatment progressed to anti-TNF therapy. 6 patients had endoscopic findings that required discussion. 30 patients where general discussion surrounding immunomodulating therapy. 7 patients had abnormal Liver function tests which required onward referral to hepatology. 22 patients had issues around general IBD management. Audit of compliance with NICE guidance improved from 80% to 100%. De-escalation of therapy and cessation of therapy accounted for a cost saving of £185,000 <h3>Conclusion</h3> The development of a nurse co-ordinated team meeting for IBD patients has facilitated a significant improvement in the overall quality of patient care, and has resulted in significant savings. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> <i>RCP standards for patients with inflammatory bowel disease</i>. London: Royal College of Physcians, 2013

Effects of Geographical Accessibility on the Use of Outpatient Care Services: Quasi-Experimental Evidence from Panel Count Data.

In 2010-2012, new outpatient service locations were established in Hungarian micro-regions, which had lacked such capacities before. We exploit this quasi-experiment to estimate the effect of geographical accessibility on outpatient case numbers using both individual-level and semi-aggregate panel data. We find a 24-27 per cent increase of case numbers as a result of the establishments. Our specialty-by-specialty estimates imply that a 1-min reduction of travel time to the nearest outpatient unit increases case numbers for example by 0.9 per cent in internal care and 3.1 per cent in rheumatology. The size of the new outpatient capacities has a separate effect, raising the possibility of the presence of supplier-induced demand. By combining a fixed-effects logit and a fixed-effects truncated Poisson estimator, we decompose the effects into increases in the probability of ever visiting a doctor on the one hand and an increase of the frequency of visits on the other hand. We find that new visits were dominant in the vast majority of specialties, whereas both margins were important for example in rheumatology. Finally, we demonstrate the usefulness of the fixed-effects truncated Poisson estimator in modelling count data by examining its robustness by simulations.

Tu1092 The Impact of a Nurse Co-Ordinated IBD Multidisciplinary Team Meeting in Enhancing Safety and Reducing Cost

Introduction The management of biologic therapy in IBD poses many challenges to clinicians. The U. K. IBD Standards 1 have highlighted the need for a structured approach to the view of patients, but this can prove difficult as a result of limitations in outpatient capacity. The gastroenterology team aimed to evaluate the impact of a multidisciplinary team (MDT) meeting on clinical outcome and cost efficiencies. Method A one hour weekly MDT meeting was established to review all in-patients with IBD and those receiving biologic therapy. In addition, clinicians discussed cases that required additional opinions in management. This was attended by Consultant gastroenterologists, IBD Nurse Specialists, dieticians, junior medical staff and consultant surgeon. Outcomes from the meeting where recorded on a database and prospectively audited. Results Within a 6 month period the IBD team meet on 22 occasions. 257 patients where reviewed (120 male, 137 female median age 36 (16–77) with IBD (210 Crohn’s disease, 39 ulcerative colitis and 3 pouchitis and 5 IBDU). Biological therapy was reviewed in 182 cases, including 136 patients requiring a routine annual review of therapy. Of the latter group, biological therapy was continued in 112/182 (61%) cases, based on continued disease activity. 18/182 (9%) patients where referred for further investigation to evaluate response to treatment and 6 where referred for outpatient clinic review. Clinical management was reviewed in 46 patients, and subsequently 18/46 patients had treatment de-escalated or ceased as a result of clinical improvement or mucosal healing. 8 patients with adverse events were reviewed and a further 8 patients had their biologic changed. 2 where referred for discussion at the medical surgical MDT. Endoscopy referrals where requested in 20 cases, MR scan in 7 cases and an urgent clinic appointment in 23 cases. A further 75 patients raised for general discussion regarding clinical management. 10 were in-patients, and 3 were referred for surgical review, a further 7 had treatment progressed to anti-TNF therapy. 6 patients had endoscopic findings that required discussion. 30 patients where general discussion surrounding immunomodulating therapy. 7 patients had abnormal Liver function tests which required onward referral to hepatology. 22 patients had issues around general IBD management. Audit of compliance with NICE guidance improved from 80% to 100%. De-escalation of therapy and cessation of therapy accounted for a cost saving of £185,000 Conclusion The development of a nurse co-ordinated team meeting for IBD patients has facilitated a significant improvement in the overall quality of patient care, and has resulted in significant savings. Disclosure of interest None Declared. Reference RCP standards for patients with inflammatory bowel disease . London: Royal College of Physcians, 2013

Innovations in practice: the inpatient liaison nurse role in endoscopy

It is quite challenging for an endoscopy department to deal with an increase in the number of outpatient endoscopies. Often, the inpatient service is carried out on an ad hoc basis and the patient lists are adjusted according to outpatient capacity. This article reviews the effect of increasing outpatient endoscopy numbers on the endoscopy unit at the Royal Liverpool Broadgreen University Hospital, and the appointment of a gastroenterology nurse specialist inpatient liaison as a method to improve the unit's efficiency. The article analyses the need for the role, the advantages its introduction has brought about, and how it has led to enhanced productivity in the respective endoscopy unit.