Outpatient Consultation Service Research Articles

EXPLORING MODELS OF CARE INTEGRATION TO ADDRESS THE NEEDS OF PERSONS AGING WITH HIV

Abstract By 2035, the majority of persons living with HIV will be 50 and older. The clinical and social needs of this population have been well documented, including the negative impacts of persistent stigma on quality of life and health outcomes. Responding to such needs requires integrated, patient-centered approaches to care and supportive services. Care integration is defined as the bringing together of two or more previously unlinked services. Care integration is used within and outside of the HIV care settings, but how such models should be designed or adapted for older persons with HIV (OPWH) is less certain given their unique needs. This symposium will explore case studies representing different models of care integration developed within and outside of HIV care settings, their relevance to OPWH, evidence of implementation including known barriers and facilitators, and opportunities to advance such models. Our first presentation describes an embedded geriatrics outpatient consultation service within an HIV care setting in New York City (Condo). Our second presentation focuses on the barriers and facilitators to the integration of substance use treatment into HIV care in Georgia (Bender). Our third and fourth presentations will describe service models developed outside of HIV care, which are now being applied to support OPWH including the Veterans Affairs patient-centered Whole Health approach (Fix) and the CAPABLE program to support aging in place (Smith). With our discussant, we will reflect on these models of integration to enhance care and support systems for this population.

Pharmaceutical care to hospital outpatients during the COVID-19 pandemic. Telepharmacy

Hospital Pharmacy Service (HPS) in Spain have been impacted by the health crisis caused by the COVID-19 pandemic. Thus, the outbreak has forced HPSs to adapt their outpatient consultation services to Telepharmacy to optimize clinical outcomes and reduce the contagion risk. The purpose of this article is to describe and analyze the experience of HPSs with hospital outpatient through Telepharmacy during the COVID-19 pandemic and expose the learned lessons. Measures have been adopted in on-site outpatient pharmacy clinics to prevent patients and professionals to virus exposure. These measures are based on national and international recommendations on social distancing and hygiene. With regard to remote outpatient pharmacy services, teleconsultation with drug dispensing has been promoted based on five basic procedures, each with its advantages and limitations: home drug delivery from HPSs, with the advantage of universal access and the limitation of entailing a substantial investment in resources; HPS coordination with primary care pharmacists, which requires no investments but with limited access to some geographic areas; HPS coordination with community pharmacists based on a large network of pharmacies, which requires the patient to go to the pharmacy, without confidentiality being guaranteed for any patient; geolocation and hospital-based medication dispensing, which provides universal access and direct traceability, but entails investment in human resources; and HPS coordination with associations of patients, which does not entail any additional cost but limits the information available on the diseases of society members. Three main lessons have been learned during the pandemic: the satisfactory capacity of HPSs to provide outpatient pharmacy consultation services in the setting of a public health crisis; the usefulness of Telepharmacy for the clinical follow-up, healthcare coordination, outpatient counseling, and informed dispensing and delivery of medication (with a high level of satisfaction among patients); and the need to foster Telepharmacy as a complementary tool through a mixed model of outpatient pharmacy consultation service that incorporates the advantages of each procedure and adapts to the individual needs of each patient in a context of humanized healthcare.

Preparing for 2023: Outpatient Consultations

This article reviews changes to codes and guidelines for reporting outpatient consultation services, including the following: Distinguishing consultations from other evaluation and management (E/M) servicesCode selection based on medical decision-making (MDM) or the total time directed to the patient’s care on the date of the encounterCodes reported to payers that do not pay for services reported with codes for consultation services

Integrating CFIR-ERIC and e-Delphi Methods to Increase Telegeriatrics Uptake.

Participatory implementation methods are needed in geriatric health care to improve care and services for a growing population of older adults. We describe an efficient participatory approach to improve uptake of Geriatric Research Education and Clinical Center (GRECC) Connect, a national geriatrics outpatient consultation service using telehealth technology to connect geriatric specialists to rural, older veterans though community-based clinics. We designed a three-phase participatory method to identify high-priority implementation strategies to support the uptake of GRECC Connect. We used the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) Strategy Matching Tool to derive expert-recommended implementation strategies informed by qualitative interviews with both GRECC Connect staff and clinicians at community-based clinics. We engaged expert panelists in a participatory two-step modified e-Delphi process using confidential surveys and discussion to prioritize strategies nationally. Qualitative interviews revealed barriers, facilitators, and recommendations for program uptake. Many strategies recommended by CFIR-ERIC addressed multiple barriers but needed to be tailored to our specific context. In our two-step e-Delphi process, expert panelists shared previous experience with the strategies presented, views on the importance and feasibility of each, and arrived at a consensus about which strategies to prioritize nationally. We demonstrate the feasibility and benefits of engaging subject matter experts to identify strategies to be tested on a national level. Future considerations include weighting of survey responses, accounting for regional differences, and sensitivity of Likert scales used in the e-Delphi process.

Addressing Access to Care in Geriatric Psychiatry through Outpatient Consultation

<h3>Introduction</h3> Article 31 clinics, under the regulation of the Office of Mental Health, have limitations in the patients that are able to be seen. In particular, patients with a primary diagnosis of neurocognitive disorder are considered ineligible for admission to such a clinic. Furthermore, many of the patients that would seek treatment at Montefiore Medical Center's Outpatient Psychiatry clinic, an Article 31 clinic, would not be able to afford private practice psychiatrists. Nevertheless, older adults with neurocognitive disorder experience symptoms that are typically managed by psychiatrists. In response to this gap in care, the Outpatient Geriatric Psychiatry team at Montefiore Medical Center developed an outpatient psychiatric consultation service to increase access to care and meet the mental health care needs of older adults living in the community. This service is provided under an Article 28 clinic, which is regulated by the Department of Health like any other medical specialty clinic. In this study, we aimed to identify which patients benefited from this service, what types of interventions were made and the impact on referring providers. This was done by collecting demographic data on patients referred for consultation and the format, frequency, and outcomes of these consultations. We also plan to collect feedback from referring providers. <h3>Methods</h3> The Geriatric Psychiatry outpatient consultation service started in December 2019 and conducted visits in person for 3 months, stopped during the 3 months of lockdown due to the COVID-19 pandemic (March to June 2020), restarted with virtual visits in July 2020 and then resumed with in person visits. Patients are referred by other providers in the Montefiore Health System or through self-referral. Patients are then screened for appropriateness for outpatient consultation. Patients who are ≥65 years old or have an underlying medical condition that contributes to their frailty, and who have a psychiatric concern are scheduled for an appointment. Efforts are made to direct those who are not appropriate for the service to more appropriate resources. In a retrospective chart review, data was gathered on patient age, referral source and reason for referral, diagnosis, format and number of visits, and outcomes of interest including medication changes, supportive services, and higher level of care. <h3>Results</h3> From December 2019 through September 2021, 38 patients were scheduled, 32 of whom presented to clinic for psychiatric evaluation. Patients ranged from 61 to 93 years old with a mean age of 79 years. A majority of patients were from ethnically diverse backgrounds with 59% Hispanic, 12.5% Black, 3% Asian and 3% American Indian. 50% of patients were Spanish speaking. About half the visits were conducted in person, with the remaining visits about evenly split between phone and video. Patients on average were seen for about 2 visits with a range from 1 to 11 visits. Most of the referrals came from primary care providers and among the reasons for referral were decline in function or cognition, behavioral concerns, depressed or anxious mood and psychosis. About 87.5% of patients had a diagnosis of major or minor neurocognitive disorder diagnosis. The most common interventions included medication changes, referral to support services, behavioral interventions, transfer to the outpatient department or sending for evaluation in the emergency department. <h3>Conclusions</h3> The Geriatric Psychiatry consultation service provided through an Article 28 clinic was primarily used by patients with neurocognitive disorders who would otherwise not be seen in Article 31 outpatient psychiatry clinics and would not be able to afford private practice. Through this service we were able to address a gap in care for a diverse and underserved patient population. In order to further assess the impact of this service, we plan to ask referring providers for feedback about the process of referral, the evaluations conducted and the recommendations received for their patients. Future studies would be helpful to collect prospective data on patients being followed by consultation service and additionally obtain patient and caregiver feedback. <h3>This research was funded by</h3> N/A Chart: https://apps.aagponline.org/abstracts/uploads/2022/gpn8zt4h8w464zu.pdf

Yoga Therapy in Cancer Care via Telehealth During the COVID-19 Pandemic.

Yoga is an evidence-based mind-body practice known to improve physical and mental health in cancer patients. We report on the processes and patient-reported outcomes of one-on-one yoga therapy (YT) consultations delivered via telehealth. For patients completing a YT consultation between March 2020 and October 2021, we examined demographics, reasons for referral, and self-reported symptom burden before and after one YT session using the Edmonton Symptom Assessment Scale (ESAS). Changes in ESAS symptom and subscale scores [physical distress (PHS), psychological distress (PSS), and global distress (GDS)] were evaluated by Wilcoxon signed-rank test. Descriptive statistics summarized the data. Ninety-seven initial YT consults were completed, with data evaluated for 95 patient encounters. The majority were women (83.2%) and white (75.8%), The mean age for females was 54.0 and for males was 53.4; the most common diagnosis was breast cancer (48%), 32.6% had metastatic disease, and nearly half (48.4%) were employed full-time. Mental health (43.0%) was the most common reason for referral, followed by fatigue (13.2%) and sleep disturbances (11.7%). The highest symptoms at baseline were sleep disturbance (4.3), followed by anxiety (3.7) and fatigue (3.5). YT lead to clinically and statistically significant reductions in PHS (mean change = -3.1, P < .001) and GDS (mean change = -5.1, P < .001) and significant reductions in PSS (mean change = -1.6, P < .001). Examination of specific symptom scores revealed clinically and statistically significant reductions in anxiety (mean change score -1.34, P < .001) and fatigue (mean change score -1.22, P < .001). Exploratory analyses of patients scoring ≥1 for specific symptoms pre-YT revealed clinically and statistically significant improvements in almost all symptoms and those scoring ≥4 pre-YT. As part of an integrative oncology outpatient consultation service, a single YT intervention delivered via telehealth contributed to a significant improvement in global, physical, and psychosocial distress. Additional research is warranted to explore the long-term sustainability of the improvement in symptoms.

Video consultation in an orthopedic trauma surgery outpatient clinic : Effective adjunctive interventions in lockdown and post-lockdown scenarios-aprospective pilot study

HintergrundIm Rahmen der Kontaktbeschränkungen aufgrund der COVID-19-Pandemie vom März 2020 wurde zur Aufrechterhaltung der Patientenversorgung eine videobasierte Sprechstunde eingeführt. Als Basis einer kontaktminimierenden Kommunikation wurde diese nach den Maßnahmen fortgeführt.Ziel der ArbeitZiel dieser prospektiven Pilotstudie ist die Beurteilung hinsichtlich der Effektivität, der technischen Machbarkeit sowie der Steuerung von Patientenströmen sowohl unter Lockdown-Bedingungen sowie in der Zeit danach.Material und MethodenDie Auswertung erfolgte vom Beginn des ersten Lockdowns am 16.03.2020 bis zum Stichtag der zweiten einschränkenden Maßnahmen am 14.12.2020. Dokumentiert wurde die Qualität der Verbindungen bezüglich Ton und Bild. Weiterhin wurden die Konsequenzen aus den Gesprächen dokumentiert. Unterschieden wurde hierbei in 4 Kategorien: 1. keine erneute Vorstellung, 2. Wiedervorstellung in der Videosprechstunde, 3. operative Therapie und 4. Vorstellung zur klinischen Untersuchung.ErgebnisseEs erfolgten 236 Patientenvorstellungen mittels Videosprechstunde. Insgesamt erfolgten 182 (82 %) Gespräche ohne Einschränkungen. Bei 47 (21 %) Konsultationen handelte es sich um Erstvorstellungen. Bei 41 (18 %) Patienten erfolgte keine erneute Vorstellung. Bei 36 (16 %) Patienten wurde eine Wiedervorstellung in der Videosprechstunde geplant, bei 36 (16 %) Patienten erfolgte die direkte Einweisung zur Operation, und bei 105 (47 %) Patienten wurde eine Wiedervorstellung zur klinischen Untersuchung vereinbart.DiskussionBei 40 % der Patienten konnte durch den Kontakt in der Videosprechstunde eine definitive Entscheidung gestellt werden. Auf der anderen Seite erfolgte bei 47 % der Patienten eine Vorstellung zur klinischen Untersuchung. Die Videosprechstunde ist eine sehr nützliche Maßnahme, um Patientenaufkommen zu leiten und den direkten Arzt-Patient-Kontakt sichtbar zu unterstützten.

A107 IMPROVING ACCESS TO URGENT GASTROENTEROLOGICAL CONSULTATION: A POSITIVE PANDEMIC IMPACT

BackgroundThe global COVID-19 pandemic has resulted in a dramatic re-alignment of clinical service delivery. In mid-March 2020 the Division of Digestive Care and Endoscopy at Dalhousie University leveraged eHealth technology to rapidly implemented a new referral management and triage system and established a new rapid outpatient consultation service to facilitate urgent virtual and face-to-face appointments. Standardized procedures for triaging, booking, and staffing the urgent gastroenterology consultation service were implemented.AimsThe aim of this study was to evaluate the impact of the implementation of a standardized triage and consultation process on access to urgent gastroenterology consultative services at a single tertiary care center during the COVID-19 pandemic.MethodsWe performed a pre- and post-implementation study comparing efficiency metrics for urgent triage and urgent consultation. The pre-implementation cohort included all patients referred and triaged to an urgent clinic appointment between April 1, 2019 to September 30, 2019. The post-implementation cohort included all patients referred and triaged to an urgent clinic appointment between April 1, 2020 to September 30, 2020.Healthcare efficiency data was extracted through electronic record review with specific dates and times for referral receipt (a), triage completion (b), appointment wait-listing (c), and clinic appointment (d). The time to triage (TT), time to visit (TV), and total time to consult (TC) were calculated (TT = c - a; TV = d - c; TC = TT + TV) for each patient. The Mann–Whitney U test was used to compare TT, TV, CT between patient cohorts.ResultsA total of 429 patients were booked for urgent clinic consultation, 176 during the pre-implementation period and 253 in the post-implementation period. The mean TT for the pre-and post-implementation cohorts was 4.8 days and 3.3 days, respectively (U=18,149, p=0.001). Mean TV was decreased from 16.2 days for the pre-implementation cohort to 3.6 days for the post-implementation cohort (U=6095, p=0.000). The mean time from a referral being received to the patient being seen in consultation (TC) decreased by 67% from 21 days to 6.9 days, Figure 1 (U=6,419, p=0.000).ConclusionsThe COVID-19 pandemic has had a dramatic impact on healthcare delivery in Nova Scotia. One positive result is that it facilitated the motivation and alignment needed to make a large health system change that may not have otherwise been possible. This study demonstrates that a standardized pathway for urgent outpatient gastroenterology assessment improves the timeliness of care delivery. Funding AgenciesNone

Development and Evolution of a Statewide Outpatient Consultation Service: Leveraging Telemedicine to Improve Access to Specialty Care.

Despite a robust health care system in the United States, many Americans experience health care disparities as a result of poor access to medical care. Academic medicine plays an important role in addressing health care disparities by providing primary and specialty care for the poor and uninsured. In South Carolina, 43 of its 46 counties are designated as fully or partially Medically Underserved Areas (MUAs), defined as areas with a shortage of medical providers, high infant mortality, and either high elderly population or high poverty rates. To address these health care disparities, an academic medical center in South Carolina created a hub-and-spoke specialty care model using telemedicine in partnership with primary care providers across community settings. Initial private foundation grant funding enabled the development and dissemination of technology to provide remote teleconsultations by physicians at the academic medical center (hub) to patients in their primary care offices (spoke). This model, now supported by recurring state funding and professional billing, provides much-needed services, including psychiatry, nutrition counseling, and various surgical and medical subspecialties, to rural and underserved populations in the state. This manuscript provides a narrative review of the development of this statewide telemedicine service, with an emphasis on identification of stakeholders, technology issues, barriers to implementation, and future directions.

Improved early diagnostics of rheumatic diseases : Monocentric experiences with an open rheumatological specialist consultation

To establish an open rheumatological outpatient consultation service for early diagnosis of inflammatory rheumatic diseases and initiation of further diagnostics and treatment. In 2015 an open consultation service was initiated for patients with signs of an early rheumatic disease after referral by primary care physicians. Patients could attend once a week without the need for a prior appointment if they fulfilled at least one of the following criteria: positive rheumatoid factor, increased CRP, anti-CCP antibody or antinuclear antibody, joint pain or back pain for over 3 months, swollen joints, fever of unknown origin or acute muscle pain with or without headache of unknown origin. This article presents the results of the retrospective descriptive data analysis of the first 2 years of this project. A total of 1262 patients were treated with an average of approximately 20patients per consultation. In nearly half of the patients an inflammatory rheumatological disease could be diagnosed and immediate diagnostic and treatment measures could be initiated. The diagnostic delay for patients with rheumatoid arthritis was 12weeks, for patients with polymyalgia rheumatica 11weeks and for patients with psoriatic arthritis or axial spondylarthritis 18 and 44weeks, respectively. The time expenditure was a total of 4-5 h per week for an experienced rheumatologist and aspecialized rheumatology nurse. Through this open rheumatological outpatient consultation a low threshold opportunity for the early diagnosis of rheumatologic diseases could be established. The diagnostic delay for many rheumatological diseases could be considerably shortened. Cooperation with rheumatologists in private practice guaranteed the subsequent specialized rheumatological care of the identified patients in the early stages of their illness.

Perinatal and early postnatal outcomes for fetuses with prenatally diagnosed d-transposition of the great arteries: a prospective cohort study assessing the effect of standardised prenatal consultation.

The aim of this study was to explore perinatal and early postnatal outcomes in fetuses with prenatally diagnosed d-transposition of the great arteries and impacts of standardised prenatal consultation. All fetuses with prenatally diagnosed d-transposition of the great arteries prospectively enrolled at South China cardiac centre from 2011 to 2015. Standardised prenatal consultation was introduced in 2013 and comprehensive measures were implemented, such as establishing fetal CHD Outpatient Consultation Service, performing standard prenatal consultation according to specifications, and establishing a multidisciplinary team with senior specialists performing in-person consultations. Continuous follow-up investigation was conducted. Perinatal and postnatal outcomes were compared before and after consultation including live birth, elective termination of pregnancy, spontaneous fetal death, stillbirths, referral for surgery, and survival. In all, 146 fetuses were enrolled with 41 (28%) lost to follow-up. Among 105 remaining fetuses, 29 (28%) were live births and 76 (72%) were terminated. After consultation, live birth rate was higher (50 versus 33%) and termination rate was lower (50 versus 76%), although there was no statistical significance. Excluding three live births without postnatal d-transposition of the great arteries, 65% (17/26) underwent arterial switch operation within 30 days. A total of three in-hospital deaths occurred and during the 10-month follow-up period, one death was observed. In one case, the switch procedure was performed at 13 months and the infant survived. Out of eight infants without arterial switch operation, two died. Live birth rate increased after consultation; however, termination remained high. Combining termination, patients without arterial switch operation, and operative mortality, outcomes of d-transposition of the great arteries infants can be improved. Standard consultation, multidisciplinary collaboration, and improved perinatal care are important to improve outcomes.

Prostate gland - what would urologists like to know from radiologists?

Amore than 100-year period, where the prostate was only seen and treated as awhole is coming to an end right now. Finally, high resolution imaging is providing deep insights and detailed information so that new therapeutic procedures can aim for the smallest targets within the gland. The long-standing wish of patients for individual noninvasive diagnostics and treatment of prostate diseases can now be fulfilled by providing new tailored concepts; however, in order to transfer the enormous amount of new information into the specific clinical patient situation, aclosely knit interdisciplinary approach is required. In this setting, the traditional outpatient consultation service is overstretched in every aspect. It is now the time for new innovative constructs. The current one-sided service concept for urologists, radiologists and radiation therapists is therefore behind the times and the development of a"prostate management team" with equally cooperating partners from each specialty is the task for the future.

USE OF TELEHEALTH (TH) IN A PEDIATRIC AMBULATORY SETTING: A PATIENT SURVEY

USE OF TELEHEALTH (TH) IN A PEDIATRIC AMBULATORY SETTING: A PATIENT SURVEY

Administration of the ASCO Pain Survey to identify patient education deficiencies in patients with cancer.

68 Background: The Doris Howell Palliative Care (PC) Outpatient Consultation Service consists of a multidisciplinary team. Reasons for consultation include pain management, treatment of other physical symptoms, education about non-drug options for pain, and advanced care planning. To assess methods used for patient education, the PC team administered the ASCO pain survey to those prescribed opioid pain medications. Methods: The survey was a 26-item questionnaire evaluating patient education content communicated by a provider to a patient during a routine clinic visit. Twenty surveys were completed anonymously. After survey review, the outpatient PC team developed an intervention to address patient education concerns. The intervention consisted of written and verbal instructions on pain medication management reviewed by the PC nurse with the patient and/or caregiver at the end of the outpatient visit. Another twenty surveys were completed anonymously with patients after intervention implementation. Time required to complete the intervention was less than two minutes per patient. The Fisher’s exact test was used to analyze the differences between surveys completed with or without the intervention. Results: The majority of patients stated that his/her provider adequately explained the use (n = 40, 100%), side effects (n = 37, 93%), and storage (n = 32, 80%) of pain medications, regardless of the intervention. Both groups also indicated that the provider and/or nurse adequately explained the risks associated with medical history (n = 34, 85%) and other medications while taking pain medications (n = 33, 83%). The intervention did increase understanding to avoid sharing pain medications (75% vs. 85%, p &lt; 0.05) and to use a lock box to secure pain medications (45% vs. 60%, p &lt; 0.05). Additionally, asking patients if family members have a history of alcohol or substance abuse was also significant (p &lt; 0.05). Conclusions: Written and verbal instructions as an intervention improved patient understanding to avoid sharing pain medications and to secure pain medications in a lock box.

Forensic Psychiatric Outpatient Consultation Service at the Psychiatric Department of Saint John Hospital, Budapest Between 2007-2014

Our forensic psychiatric outpatient consultation service for the Main Detention Centre of Budapest (MDC) started in 2007 May. Before our consultations the clients are examined by the medical doctor of the MDC, and his/her decision to ask for psychiatric examination with specific questions. The clients are transferred by the police to the hospital. We analysed retrospectively all the cases of 7 years. Objectives statistical and qualitative analysis of clients’ reports of 529. The clients were before judicial process and detained in custody in the MDC. Aims to analyse the frequent problems and the clinical questions by the referral doctors, the necessity of these problems, and the severity of the clients symptoms. Methods We analysed all the files, and the objectives: referral diagnosis, diagnosis after our examination, suicide intentions, intentional aggravation, heteroagression, psychiatric history, drug use and dependency, current medication, presence of psychotic symptoms. Results Between 2007-2014 September there were 529 examinations. The most frequent question was to evaluate the suicide risk and to measure the necessity of the admission to an acute psychiatric unit. The number of the referrals remains 80-90 per year since 2012, 33% of the examined clients were diagnosed with personality disorder at our unit. Conclusion Specialised service is needed (Forensic Psychiatric Unit) to evaluate more precisely the severity of suicide risk, and to exclude the intentional behaviour. Consultation and training of the MDC medical staff can enhance the more precise psychiatric evaluation especially to differentiate between personality and major psychiatric disorders.

How much orientation towards the host culture is healthy? Acculturation style as risk enhancement for depressive symptoms in immigrants.

As the specific acculturative tasks and challenges involved in the migration process can lead to an increased risk for depressive symptoms, the study was designed to gain further insight into the interrelation between acculturation styles and mental health. A total of n = 90 patients with different ethnic backgrounds from an outpatient consultation service for immigrants at the Hannover Medical School were investigated by the Hannover Migration and Mental Health Interview (HMMH), the Centre for Epidemiologic Studies Depression Scale (CES-D) and the Frankfurt Acculturation Scale (FRAKK). The majority of the subjects (84.4%) had a clinically significant depression. The extent of depressive symptoms was determined by the selected acculturation style (1) (F = 3.29, p = .025): Subjects with integration as acculturation style showed less depressive symptoms than subjects with assimilation as acculturation style. Furthermore, subjects with segregation as acculturation style also showed less depressive symptoms than subjects with assimilation. The results suggest that even when undergoing extreme emotional distress, eventually leading to mental disorder, integration, as an acculturation style, seems to serve as a protective resource and possibly prevents further decline.

Examining patients' preferences for participation in clinical decision-making: the experience in a Latin American chronic obstructive pulmonary disease and cancer outpatient population

It is generally accepted that patients prefer to be told the truth by their physicians; however, the practice of partial truth-telling is frequent with an existing 'norm of nondisclosure.' Our primary objective was to determine what patients wanted to be told about their illness, and whether there might be differences between patients with either cancer or advanced chronic obstructive pulmonary disease (COPD). A second objective was to determine how these patients envisioned their participation, or lack thereof, in the treatment decision-making process. Subjects were eligible for this prospective study if they were attending the oncology or pulmonary outpatient consultation services at the British Hospital or the Sanatorio Güemes Private Hospital in Buenos Aires, Argentina between June 2009 and May 2010. Ninety-nine patients were recruited. Forty-four had a diagnosis of COPD, and 55 patients had cancer. Seventeen of the patients expected their health to improve in the future, but a significantly higher proportion of patients with malignant disorders expected to get better in the near future as compared with those with COPD (98.2% vs 62.8%, P < 0.001). Most study participants expressed a desire to receive all the information available about their condition. A majority of the participants expressed a preference for making treatment decisions in collaboration with their physician (40.4%) While they considered the role of their families relevant and wanted information to be shared so that family members might participate in decision-making, they did not want their families to have a right to withhold information, make final decisions.

2373 – Forensic psychiatric outpatient consultation service at a general hospital psychiatric department setting in budapest. Five-year experience: conclusions, further suggestions

Introduction Due to the unprofessional closure of the Hungarian National Institute of Psychiatry and Neurology at 2007, the forensic psychiatric outpatient consultation service of the Main Detention Centre of Budapest (MDC), was officially transferred to the Psychiatric Department of Saint John Hospital. Hungary has had neither a Forensic Psychiatric Unit nor a single Security Units Department. At our psychiatric department first we started operating this type of consultation. in 2007 May. Before our consultations the clients are examined by the medical doctor of the MDC, and his/her decision to ask for psychiatric examination with specific questions. We analysed retrospectively these cases of 5 years. Objectives Statistical and qualitative analysis of clients’ reports of 346. The clients were before judicial process and detained in custody or before it in the MDC. Aims To analyse the frequent problems and questions, the necessity of these problems, and severity of the clients symptoms. Methods We analysed all the files, and the objectives: referral diagnosis, diagnosis after our examination, suicide intentions, intentional aggravation, heteroagression, psychiatric history, drug use and dependency, current medication, presence of psychotic symptoms. Results Between 2007–2009 August there were 67 examinations, and between 2009 September and 2012 were 280 visits. The most frequent question was to evaluate the suicide risk. (three-quarter of the sample.) Conclusion Specialised service is needed (Forensic Unit) to evaluate more precisely the severity of suicide risk, and to exclude the intentional behaviour. External causes may influence the higher number of the cases, after 2009 August.

Pharmacist-based Donepezil Outpatient Consultation Service to improve medication persistence

AimDonepezil is widely used to delay the progression of cognitive dysfunction in patients with Alzheimer’s disease (AD), but the efficacy of pharmacotherapy is often reduced by poor adherence to medication. In order to improve adherence by providing information about AD and the significance of pharmacotherapy, the Donepezil Outpatient Consultation Service (DOCS) was set up. The influence of this service on medication persistence was assessed in the present study.MethodsAmong outpatients starting donepezil therapy, we enrolled 59 patients between April 2008 and September 2010 before establishment of the DOCS (non-DOCS group) and 52 patients between October 2010 and March 2012 who attended the DOCS (DOCS group). Each patient’s and their caregiver’s understanding about the clinical features of AD and pharmacotherapy with donepezil were also assessed. Their understanding was compared before and after the DOCS, and the 1-year medication persistence rate and the reasons for discontinuation were also investigated.ResultsThe 1-year medication persistence rate was significantly higher in the DOCS group than in the non-DOCS group (73.1% vs 49.2%, P = 0.008). We examined the association of medication persistence with age, sex, clinical dementia rating, living alone, and attending the DOCS. As a result, medication persistence was significantly higher in patients attending the DOCS. The main reasons for discontinuation of donepezil were transfer elsewhere (11) and gastrointestinal side effects (5) in the non-DOCS group, and transfer (9) and gastrointestinal side effects (3) in the DOCS group. The overall score for understanding was 2.5 ± 1.7 before attending the DOCS and it increased significantly to 5.7 ± 0.7 afterward (P < 0.001).ConclusionThe DOCS consultation provided by hospital pharmacists for AD patients and their caregivers improved understanding about the clinical features of dementia and provided pharmacological knowledge about antidementia drugs, leading to better adherence to pharmacotherapy that could maximize its effect.

Assessing the risks of service failures based on ripple effects: A Bayesian network approach

Abstract This study responds to the need for assessing risks of service failures by focusing on ripple effects. We propose a Bayesian network approach to assessing risks of service failures based on the depdendence relationships among individual service failures. To avoid conceptual misunderstanding and imprecise use in practice, the suggested approach is designed to be executed in three consecutive stages: modeling a Bayesian network; assessing the risks in terms of probabilities of service failures (PSFs) and impacts of service failures (ISFs); and developing a service failure assessment map. A case study of the outpatient consultation service is presented to show the feasibility of our method.