Outpatient Scenarios Research Articles

Evaluating Large Language Model–Supported Instructions for Medication Use: First Steps Toward a Comprehensive Model

ObjectiveTo assess the support of large language models (LLMs) in generating clearer and more personalized medication instructions to enhance e-prescription. Patients and MethodsWe established patient-centered guidelines for adequate, acceptable, and personalized directions to enhance e-prescription. A dataset comprising 104 outpatient scenarios, with an array of medications, administration routes, and patient conditions, was developed following the Brazilian national e-prescribing standard. Three prompts were submitted to a closed-source LLM. The first prompt involved a generic command, the second one was calibrated for content enhancement and personalization, and the third one requested bias mitigation. The third prompt was submitted to an open-source LLM. Outputs were assessed using automated metrics and human evaluation. We conducted the study between March and September 2024. ResultsAdequacy scores of our closed-source LLM’s output showed the third prompt outperforming the first and second one. Full and partial acceptability was achieved in 94.3% of texts with the third prompt. Personalization was rated highly, especially with the second and third prompts. The 2 LLMs showed similar adequacy results. Lack of scientific evidence and factual errors were infrequent and unrelated to a particular prompt or LLM. The frequency of hallucinations was different for each LLM and concerned prescriptions issued upon symptom manifestation and medications requiring dosage adjustment or involving intermittent use. Gender bias was found in our closed-source LLM’s output for the first and second prompts, with the third one being bias-free. The second LLM’s output was bias-free. ConclusionThis study demonstrates the potential of LLM-supported generation to produce prescription directions and improve communication between health professionals and patients within the e-prescribing system.

Analysis of the shorter drug survival times for Janus kinase inhibitors and interleukin-17 inhibitors compared with tumor necrosis factor inhibitors in a real-world cohort of axial spondyloarthritis patients - a retrospective analysis from the RHADAR network

In recent years Janus kinase inhibitors (JAKi) have joined tumor necrosis factor inhibitors (TNFi) and interleukin (IL)-17 inhibitors (IL-17i) as approved disease modifying anti-rheumatic drugs (DMARD) for moderate to severe forms of axial spondyloarthritis (axSpA). Drug survival in axSpA patients has not been well studied in a real-world outpatient scenario since the approval of JAKi. We aimed to analyze the three drug classes based on modes of actions (MoA) for their persistence rates among German axSpA outpatients. A retrospective analysis of the RHADAR database for axSpA patients with a new initiation of TNFi, IL-17i, or JAKi treatment between January 2015 and October 2023 was conducted. Analyses included Kaplan-Meier curves and adjusted Cox regressions for drug discontinuation. 1222 new biological DMARD (TNFi [n = 954], IL-17i [n = 190]) or JAKi (n = 78) treatments were reported. The median drug survival was 31 months for TNFi, 25 for IL-17i, and 18 for JAKi. The corresponding 2-year drug survival rate was 79.6%, 72.6%, and 62.8% for TNFi, IL-17i, and JAKi, respectively. The probability for discontinuation for JAKi was significantly higher compared with TNFi (HR 1.91 [95% CI 1.22–2.99]) as well as for IL-17i compared with TNFi (HR 1.43 [95% CI 1.02–2.01]), possibly related to more frequent use of TNFis as first-line therapy. IL-17i and JAKi discontinuation probabilities were similar. Primary non-response was the reason for drug discontinuation in most cases across all MoA. TNFi treatment might persist longer than JAKi and IL-17i in German axSpA outpatients, possibly related to more severe or refractory disease in patients with JAKi-treated or IL-17i-treated axSpA.

A self-reported symptom-based decision-making model helps to rule out outpatient cases at low risk for CRC before colonoscopy

ObjectivesEffective exclusion of low-risk symptomatic outpatient cases for colorectal cancer (CRC) remains diagnostic challenges. We aimed to develop a self-reported symptom-based decision-making model for application in outpatient scenarios. MethodsIn total, 8233 symptomatic cases at risk for CRC, as judged by outpatient physicians, were involved in this study at seven medical centers. A decision-making model was constructed using 60 self-reported symptom parameters collected from the questionnaire. Further internal and external validation cohorts were built to evaluate the discriminatory power of the CRC model. The discriminatory power of the CRC model was assessed by the C-index and calibration plot. After that, the clinical utility and user experience of the CRC model were evaluated. ResultsNine symptom parameters were identified as valuable predictors used for modeling. Internal and external validation cohorts verified the adequate discriminatory power of the CRC model. In the clinical application step, all 17 physicians found the model easy to grasp, 99.9 % of the patients were satisfied with the survey form. Application of this model detected all CRC cases. The total consistency ratio of outpatient cases undergoing colonoscopy was 81.4 %. None of the low-risk patients defined by the CRC model had been diagnosed with CRC. ConclusionThis multicenter study developed and validated a simple and user-friendly decision-making model covering self-reported information. The CRC model has been demonstrated to perform well in terms of rapid outpatient decision-making scenarios and clinical utility, particularly because it can better rule out low-risk outpatient cases.

Ineffective health management in people with hypertension: Accuracy study.

To analyze the accuracy of the clinical indicators of the nursing diagnosis Ineffective Health Management in people with hypertension. This is a cross-sectional diagnostic accuracy study. The ineffective health management was investigated in 120 people with hypertension in a referral public outpatient clinic in Brazil between August and November 2020. The accuracy measures were analyzed using Rasch analysis, considering the difficulty of clinical indicator and person's ability. Ineffective health management is probably present in 37.5% of people with hypertension. 'Failure to include treatment regimen in daily living' was the clinical indicator with the highest sensitivity value, and 'failure to take action to reduce risk factor' had the highest specificity value. Rasch analysis demonstrated that all clinical indicators contribute significantly to estimating the presence of ineffective health management in people with hypertension in the outpatient scenario. This research contributes by providing accurate clinical indicators of ineffective health management, helping nurses prescribe and deliver the appropriate nursing interventions for people with hypertension by telenursing.

Characterizing the Medical Pertinence for the Indication of a Bone Scan by Urologists, in Patients with Prostate Cancer

<i>Introduction</i>: Prostate cancer (PC) is the second most frequently diagnosed tumor in men, and bone scan (BS) is one of the diagnostic images used for staging and follow-up. Precise indications for performing a BS exist and an overuse of this diagnostic modality is suspected. It is relevant to evaluate the medical pertinence when requesting a BS to promote self-regulation, protect the health system and reduce radiation doses. <i>Methods</i>: This is a descriptive, retrospective study. Medical records of patients with PC diagnosis were reviewed. We included patients evaluated by a urologic oncologist at the outpatient scenario, at San Ignacio Hospital, Bogotá, Colombia, in the second trimester of 2019. Epidemiological and staging data were recorded for each patient, as well as the number of BS requested, the type of BS performed, the PSA at the time of performance and the impact of the result on medical decisions. Clinical indications for requesting a BS were classified, according to RADAR III guidelines. An analysis was performed using Excel (measures of central tendency and frequency). <i>Results</i>: A total of 234 patients were evaluated (mean age: 74.47 years; mean follow-up time: 32.3 months). At least one BS was requested in 55% of patients (mean 1.54), with a total of 199 BS performed. The most frequent indication for a BS was PSA progression in patients with androgen deprivation therapy (ADT), in hormone-sensitive prostate cancer (31%). 18% of the requested BS could have been omitted (inappropriate indication). The mean PSA at performance for BS that showed bone metastasis (33%) was 151.27ng/ml and 19.75ng/ml for those negative (67%). Medical behavior was not impacted by the result of any of the BS that didn´t have an appropriate indication according to the established guidelines, but it was affected by 85% of those correctly requested. <i>Discussion and Conclusions</i>: BS is a conventional image that it widely performed for the staging and follow-up of PC. There are precise indications according to the NCCN and RADAR III guidelines for performing one in a PC patient. It was observed that with some frequency it is requested unnecessarily, without having any impact on the clinical decisions for the patient. The relevance of medical self-regulation and knowledge of scientific evidence are highlighted to prevent unnecessary exposure to radiation, optimize the impact of the results of these tests on clinical behavior and protect the health system.

Willingness of medical students to refer patients to a physician associate or a doctor based on clinical scenarios when time is a trade-off

Background: The Physician Associate (PA) role was introduced in Ireland in 2015 in an effort to bolster medical services. From the perspective of the patient and staff they have been well received. However, the attitude of medical students about PAs is not known.Objective: To investigate the willingness of medical students to refer patients to a PA or a doctor.Methods: A quantitative study was undertaken using an online survey with a sample of 1,909 undergraduate and graduate entry medical students. Based on three outpatient scenarios, they were asked, in their role as future intern (PGY1), to choose a referral to a PA or a doctor, with six time trade-off options offered. Year of study, country of residence and working or treatment experience with PAs and Nurse Practitioners were recorded. Descriptive statistics, and logistic regression models were used.Results: In 2019, in Dublin, 177 medical students took part in the survey. Those surveyed were international and domestic nationals. Overall the PA option was chosen where the patient’s wait time was shorter and the clinical condition was perceived more serious. The doctor option was selected more readily when the wait time difference was less significant. Respondents from countries with established PA roles may have had experience to choose PAs than naïve ones.Conclusion: This study confirms that medical students’ willingness to refer a patient is influenced by familiarity with the PA role and severity of the medical condition. In addition wait time is a primary motivator for selecting the PA over doctor option. These findings suggest a need to improve communication about the PA role among Irish medical students.

Physician use of speech recognition versus typing in clinical documentation: A controlled observational study

ImportanceSpeech recognition (SR) is increasingly used directly by clinicians for electronic health record (EHR) documentation. Its usability and effect on quality and efficiency versus other documentation methods remain unclear. ObjectiveTo study usability and quality of documentation with SR versus typing. DesignIn this controlled observational study, each subject participated in two of five simulated outpatient scenarios. Sessions were recorded with Morae® usability software. Two notes were documented into the EHR per encounter (one dictated, one typed) in randomized order. Participants were interviewed about each method’s perceived advantages and disadvantages. Demographics and documentation habits were collected via survey. Data collection occurred between January 8 and February 8, 2019, and data analysis was conducted from February through September of 2019. SettingBrigham and Women’s Hospital, Boston, Massachusetts, USA. ParticipantsTen physicians who had used SR for at least six months. Main outcomes and measuresDocumentation time, word count, vocabulary size, number of errors, number of corrections and quality (clarity, completeness, concision, information sufficiency and prioritization). ResultsDictated notes were longer than typed notes (320.6 vs. 180.8 words; p = 0.004) with more unique words (170.9 vs. 120.4; p = 0.01). Documentation time was similar between methods, with dictated notes taking slightly less time to complete than typed notes. Typed notes had more uncorrected errors per note than dictated notes (2.9 vs. 1.5), although most were minor misspellings. Dictated notes had a higher mean quality score (7.7 vs. 6.6; p = 0.04), were more complete and included more sufficient information. Conclusions and relevanceParticipants felt that SR saves them time, increases their efficiency and allows them to quickly document more relevant details. Quality analysis supports the perception that SR allows for more detailed notes, but whether dictation is objectively faster than typing remains unclear, and participants described some scenarios where typing is still preferred. Dictation can be effective for creating comprehensive documentation, especially when physicians like and feel comfortable using SR. Research is needed to further improve integration of SR with EHR systems and assess its impact on clinical practice, workflows, provider and patient experience, and costs.

Optimal Laxatives for Oral Colonoscopy Bowel Preparation: from High-volume to Novel Low-volume Solutions

Optimal bowel preparation is essential for a more accurate, comfortable, and safe colonoscopy. The majority of postcolonoscopy colorectal cancers can be explained by procedural factors, mainly missed polyps or inadequate examination. Therefore the most important goal of optimal bowel preparation is to reduce the incidence of colorectal cancer. Although adequate preparation should be achieved in 85-90% or more of all colonoscopy as a quality indicator, unfortunately 20-30% shows inadequate preparation. Laxatives for oral colonoscopy bowel preparation can be classified into polyethylene glycol (PEG)-electrolyte lavage solution, osmotic laxatives, stimulant laxatives, and divided into high-volume solution (≥3 L) and low-volume solution (<3 L). The updated 2019 European Society of Gastrointestinal Endoscopy (ESGE) guideline is broadly similar to the 2014 American Society for Gastrointestinal Endoscopy (ASGE) recommendations and reaffirms the importance of split-dosing. However, new ESGE guideline, unlike the 2014 ASGE recommendation, suggests the use of high volume or low volume PEG-based regimens as well as that of non-PEG based agents that have been clinically validated for most outpatient scenarios. For effective, safe, and highly adherent bowel preparation, physicians who prescribe and implement colonoscopy should properly know the advantages and limitations, the dosing, and the timing of regimens. Recently many studies have attempted to find the most ideal regimens, and more convenient, effective, and safe regimens have been developed by reducing the dosing volume and improving the taste. The high tolerability and acceptability of the new low-volume regimens suggest us how we should use it to increase the participation of the national colorectal cancer screening program.

Assessing the economic value of avoiding hospital admissions by shifting the management of gram+ acute bacterial skin and skin-structure infections to an outpatient care setting

Objective:To estimate, from a US payer perspective, the cost offsets of treating gram positive acute bacterial skin and skin-structure infections (ABSSSI) with varied hospital length of stay (LOS) followed by outpatient care, as well as the cost implications of avoiding hospital admission.Methods:Economic drivers of care were estimated using a literature-based economic model incorporating inpatient and outpatient components. The model incorporated equal efficacy, adverse events (AE), resource use, and costs from literature. Costs of once- and twice-daily outpatient infusions to achieve a 14-day treatment were analyzed. Sensitivity analyses were performed. Costs were adjusted to 2015 US$.Results:Total non-drug medical cost for treatment of ABSSSI entirely in the outpatient setting to avoid hospital admission was the lowest among all scenarios and ranged from $4039–$4924. Total non-drug cost for ABSSSI treated in the inpatient setting ranged from $9813 (3 days LOS) to $18,014 (7 days LOS). Inpatient vs outpatient cost breakdown was: 3 days inpatient ($6657)/11 days outpatient ($3156–$3877); 7 days inpatient ($15,017)/7 days outpatient ($2495–$2997). Sensitivity analyses revealed a key outpatient cost driver to be peripherally inserted central catheter (PICC) costs (average per patient cost of $873 for placement and $205 for complications).Limitations:Drug and indirect costs were excluded and resource use was not differentiated by ABSSSI type. It was assumed that successful ABSSSI treatment takes up to 14 days per the product labels, and that once-daily and twice-daily antibiotics have equal efficacy.Conclusion:Shifting ABSSSI care to outpatient settings may result in medical cost savings greater than 53%. Typical outpatient scenarios represent 14–37% of total medical cost, with PICC accounting for 28–43% of the outpatient burden. The value of new ABSSSI therapies will be driven by eliminating the need for PICC line, reducing length of stay and the ability to completely avoid a hospital stay.

Obstetrics and gynecology outpatient scenario of an Indian homeopathic hospital: A prospective, research-targeted study

The authors aimed to document prescriptions and clinical outcomes in routine homeopathic practice to short list promising areas of targeted research and efficacy trials of homeopathy in obstetrics and gynecology (O&G).Three homeopathic physicians participated in methodical data collection over a 3-month period in the O&G outpatient setting of The Calcutta Homeopathic Medical College and Hospital, West Bengal, India. A specifically designed Excel spreadsheet was used to record data on consecutive appointments, including date, patient identity, socioeconomic status, place of abode, religion, medical condition/complaint, whether chronic/acute, new/follow-up case, patient-assessed outcome (7-point Likert scale: −3 to +3), prescribed homeopathic medication, and whether other medication/s was being taken for the condition. These spreadsheets were submitted monthly for data synthesis and analysis.Data on 878 appointments (429 patients) were collected, of which 61% were positive, 20.8% negative, and 18.2% showed no change. Chronic conditions (93.2%) were chiefly encountered. A total of 434 medical conditions and 52 varieties were reported overall. The most frequently treated conditions were leucorrhea (20.5%), irregular menses (13.3%), dysmenorrhea (10%), menorrhagia (7.5%), and hypomenorrhea (6.3%). Strongly positive outcomes (+3/+2) were mostly recorded in oligomenorrhea (41.7%), leucorrhea (34.1%), polycystic ovary (33.3%), dysmenorrhea (28%), and irregular menses (22.2%). Individualized prescriptions predominated (95.6%). A total of 122 different medicines were prescribed in decimal (2.9%), centesimal (87.9%), and 50 millesimal potencies (4.9%). Mother tinctures and placebo were prescribed in 3.4% and 30.4% instances, respectively. Several instances of medicine-condition pairings were detected.This systematic recording cataloged the frequency and success rate of treating O&G conditions using homeopathy.

Toward Detection and Monitoring of Gait Pathology using Inertial Sensors under Rotation, Scale, and Offset Invariant Dynamic Time Warping

Walking ability can be degraded by a number of pathologies, including movement disorders, stroke, and injury. Personal activity tracking devices gather inertial data needed to measure walking quality, but the required algorithmic methods are an active area of study. To detect changes in walking ability, the similarity between a person’s current gait cycles and their known baseline gait cycles may be measured on an ongoing basis. This strategy requires a similarity measure robust to variability encountered in an outpatient scenario, including changes in walking surface, walking speed, and sensor orientation. Here we propose rotation, scale, and offset invariant dynamic time warping (RSOI-DTW), a variant of the well-known dynamic time warping (DTW) algorithm, as a generalization of DTW appropriate for three-dimensional inertial data. RSOI-DTW is invariant under rotation, scaling, and offset, yet it preserves the salient features of gait cycles required for gait monitoring. To support this claim, gait cycles from 21 subjects walking with four different styles were compared using both DTW and RSOI-DTW. The data show that RSOI-DTW converges quickly and achieves rotation, scale, and offset invariance. Both algorithms distinguish persons and detect abnormal walking, but only RSOI-DTW does so in the presence of sensor rotation. Variations in walking speed pose a challenge for both algorithms, but performance is improved by collecting baseline information at a variety of speeds.

Human Papillomavirus infection is not highly prevalent in oral and laryngeal dysplasia and is not associated with progression to dysplasia

Methods: 75 non-continuous patients with mandibular fractures were included retrospectively. Cases were deemed suitable for DSU if they had a Mandible Injury Severity Score < 10, and were medically/socially appropriate for DSU. Comparative cost calculations were performed for inpatient and outpatient scenarios. These included:bed-day cost, theatre time, consumables and staffing. Results: Overall average delay from admission to surgery was 0.9 days and inpatient length of stay (IPLOS) was 1.8 days. Of the seven patients assessed as suitable for DSU; mean delay to surgery was 1 day, and IPLOS 1.6 days. Cost comparison and financial savings: Inpatient and DSU theatre costs are comparable at £213.64 and £211.69 per 15mins respectively. Potential inpatient bed-day earnings are £1831. There is a premium ‘intermediate OMFS procedure’ Healthcare Resource Group tariff of £102.80 as DSU over inpatient. Conclusion: A conservative 10% of mandibular fractures can be safely managed as outpatients. This should increase as the DSU service gains experience handling more complex fractures. A business case can be made to establish a rapidaccess link to existing DSU lists to release inpatient beds in a safe manner on the basis of increased income and decreased expenditure.

PMH38 - Hospitalization costs in schizophrenia (SC) and projection of costs with the adoption of a long-term release formulation of paliperidone palmitate (LRPP): real world data analysis

Schizophrenia is a mental disease of chronic nature that may often require long time hospitalizations to be controlled. One of the major issues in controlling Sc is adherence to treatment. Long-term release paliperidone palmitate administered intramuscularly once a month improved treatment compliance and diminished hospitalization rates. Our goal was to estimate the costs of hospitalization for schizophrenic patients in Brazil (private setting) and to calculate the monetary impact of adopting LRPP in an outpatient scenario. We searched a database of claims of five health plans in order to identify patients with schizophrenia. Then, we retrieved all hospitals bills for each patient and determined the final cost of admissions. Only direct costs were considered: medication, medical visits, ancillary fees, etc. To project the impact of the adoption of LRPP, we estimated that hospitalization rates would be reduced by 31.5% for patients admitted for less than one year and 35.9% for those hospitalized for up to two years, according to data from randomized trials. We identified 18 admissions due to schizophrenia. Patients had a mean age of 43.4 years. Mean length of hospitalization was 126.4 days, corresponding to a total of 2275 days for all patients. Total hospitalization cost was R$ 604 889 (US$ 252 037), mean of R$ 33 604 (US$ 14 000) per hospitalization. If LRPP was adopted, the cost to treat these patients would be cut down to R$ 130 974 (US$ 54 572), a reduction of 21,65%. Based on real world data, Sc hospitalization costs may be reduced by 21% if outpatient treatment with LRPP is adopted.

EFisioTrack: A Telerehabilitation Environment Based on Motion Recognition Using Accelerometry

The growing demand for physical rehabilitation processes can result in the rising of costs and waiting lists, becoming a threat to healthcare services' sustainability. Telerehabilitation solutions can help in this issue by discharging patients from points of care while improving their adherence to treatment. Sensing devices are used to collect data so that the physiotherapists can monitor and evaluate the patients' activity in the scheduled sessions. This paper presents a software platform that aims to meet the needs of the rehabilitation experts and the patients along a physical rehabilitation plan, allowing its use in outpatient scenarios. It is meant to be low-cost and easy-to-use, improving patients and experts experience. We show the satisfactory results already obtained from its use, in terms of the accuracy evaluating the exercises, and the degree of users' acceptance. We conclude that this platform is suitable and technically feasible to carry out rehabilitation plans outside the point of care.

Board 326 - Research Abstract Not All Raters are Created Equal

Introduction/Background The need for interprofessional collaboration is clear: healthcare providers must work on cross-professional teams to coordinate patient care and reduce the propensity for errors.1 While interprofessional education (IPE) programs recently became mandatory for MD-granting education programs,*researchers have noted the dearth of published evaluation tools for directly observing and measuring collaboration competencies.2 Interprofessional simulations provide an important opportunity to meet this need for individual assessment and program evaluation. However, current limitations in the teamwork-simulation assessment literature include: 1) little data on sources of error variance affecting reliability, and 2) failure to include ambulatory (outpatient) teamwork scenarios (i.e., everyday teamwork aside from emergency, surgical and hospital settings). We have developed a broader use ambulatory teamwork simulation3 and now evaluate the reliability of a competency assessment for this scenario. In particular, we used generalizability theory to estimate reliability estimates for sub-samples of raters, thereby identifying individual raters who are less closely calibrated with others. *ED-19-A was approved July 1, 2013; http://www.lcme.org. Methods Six observers rated collaborative behaviors for each of twenty one students on the interprofessional collaboration simulation in a fully crossed design. Each simulation involves a single student interacting with a standardized patient and caregiver and standardized clinicians, all portrayed by live actors. The outpatient scenario challenges students to place the patient at the center of the healthcare team, to include the caregiver on that team and to work collaboratively with other health care providers.3 Observers rated student performance (from video recordings) on 21 behaviors including collaboration, communication and acting as an advocate for the patient. The 21 student performance ratings were analyzed using generalizability theory.4 Results Mean average scores were calculated for each student across the six raters. Student scores ranged from 8.67 to 16.3 out of 21 possible, with a mean of 12.6 (SD = 2.1). The following variance components were estimated with the SPSS VARCOMP procedure: Student (1.7% of total variance), Rater (1.2%), Item (15.7%), Student x Rater (2.5%), Rater x Item (7.4%), Student x Item (36%) and the Student x Item x Rater term plus residual error (35.5%). The G coefficient for 6 raters and 21 fixed items was .78. Most of the systematic variance was attributed to student differences in performance on different competencies (items); overall student scores were a relatively small source of variance. A small proportion of variance in ratings was due to rater differences. A decision study was conducted to estimate the reliability expected with different numbers of raters. Using the above variance components, G coefficients for 2 to 7 raters were estimated, ranging from .53 to .80. In addition, we estimated the G coefficient by randomly extracting one of the study’s raters from the sample at a time in order to determine if any particular raters were less well calibrated with the others. These “reliability if rater deleted” estimates showed modest variability (.71, .71, .75, .76, .79, .81), in the latter two cases increasing beyond the .78 value expected for six raters and thus contradicting the expected benefit of increasing numbers of raters. Conclusion Results indicate the measurement protocol could yield a reliable assessment of ambulatory interprofessional collaboration; however, multiple raters were needed –at least five and as many as seven to achieve the desired .80. While adding raters is generally expected to improve reliability, it is unlikely that all raters are equally well calibrated and we observed increases when two specific raters were excluded. Other researchers may find value in the use of generalizability theory to diagnose rater-specific issues affecting reliability. Based on such statistics, researchers might elect to offer extra training or exclude raters who are less calibrated with the group.

The “Usual Care” Quality Conundrum: A Call to Action

The synthesis of current knowledge about specialty outpatient children’s mental health care in this article provides a sobering reminder that we have effectively been ‘‘asleep at the wheel’’ when it comes to comprehensive evaluation of the quality of mental health services being provided to children and families. In this new age of health care reform, this is a travesty that cannot stand. We cannot be complacent and be steamrolled into accepting anything less than the rigorous evaluation of what is being provided to youth and families in ‘‘usual care’’ settings. The fact that this selective review focuses primarily on services provided in specialty outpatient mental health settings is precisely why readers should pay attention. It is of grave concern to me that this is exactly the type of care that will be supported by health care reform initiatives. A chilling pall comes over this reader as the authors detail the ineffectiveness of usual care. I can’t help but ask the question––If usual care is ineffective, what will be supported in health care reform? Actually, that’s a rhetorical question because it is precisely ‘‘usual care’’ that will likely be supported in health care reform. And if that doesn’t get your attention and make you want to review this article with great care and attention to the macro level of quality children’s mental health care, then you are in the wrong business. Usual care should be radically broadened to include a robust family partner component along with access to family-driven respite care and innovative mobile crisis response options, to name but a few key ingredients that go far beyond the typical outpatient care scenario. Garland, et al. shines a bright light into the dark corners of traditional mental health delivery. They note that 68 % of the care in the studies reviewed were clinic based. A sobering reminder of how fragile our current mental health services are is the finding that ‘‘a third of the directors with site-specific budget data indicated that their agency ran at a budget deficit.’’ This is so important for advocates to understand. For us, ‘‘what works’’ goes far beyond usual care. It involves the active participation of community groups and families and initially may cost more. Yet, a third of Clinic Systems Project (CSP) cited in the article ran at a deficit and the largest funding source was Medicaid, which has what I consider to be narrowly fundable criteria, i.e., ‘‘usual care.’’ Are you starting to get the picture? If we allow policy makers to just fund what we do now, (i.e., usual care) without doing rigorous quality checks, then we are doomed to a mediocre at best mental health service delivery system. We need a system that evaluates and supports services beyond usual care if we are going to make significant improvements. Garland et al. (2013) identify studies that show that the majority of children receiving community-based ‘‘usual care’’ do not show clinical improvement. We need much more research to find examples of excellence and promote them so that funders can see the impact––clinically, financially and overall improvement in the family and community. The article also talks about promising strategies, including integration of behavioral health with services such as primary care and education. Traditional outpatient care is dead in my opinion. It’s just that those practicing it Improving community-based mental health care for children: Translating knowledge into action, by Ann F. Garland, Rachel HaineSchlagel, Lauren Brookman-Frazee, Mary Baker-Ericzen, Emily Trask, Kya Fawley-King.

Strategy for Data Stream Processing Based on Measurement Metadata: An Outpatient Monitoring Scenario

In this work we discuss SDSPbMM, an integrated Strategy for Data Stream Processing based on Measurement Metadata, applied to an outpatient monitoring scenario. The measures associated to the attributes of the patient (entity) under monitoring, come from heterogeneous data sources as data streams, together with metadata associated with the formal definition of a measurement and evaluation project. Such metadata supports the patient analysis and monitoring in a more consistent way, facilitating for instance: i) The early detection of problems typical of data such as missing values, outliers, among others; and ii) The risk anticipation by means of on-line classification models adapted to the patient. We also performed a simulation using a prototype developed for outpatient monitoring, in order to analyze empirically processing times and variable scalability, which shed light on the feasibility of applying the prototype to real situations. In addition, we analyze statistically the results of the simulation, in order to detect the components which incorporate more variability to the system.

Syncope

Pulmonary embolism is a very infrequent event in previously healthy children, particularly in the outpatient scenario. This report involves a 7-year-old girl who presented to the emergency room after syncope. A prompt diagnostic workup showed a massive pulmonary embolism. A timely treatment initiation permitted a good and rapid response. She represented a diagnostic and treatment challenge, mainly because of the atypical presentation and the absence of known risk factors. Finally, a thorough study uncovered a nephrotic-range urine protein loss. At the beginning, the patient did not meet the whole nephrotic syndrome diagnostic requirements. The complete thombophilic study was normal. The clinical presentation, epidemiology, diagnostic tools and the treatment of pulmonary embolism are reviewed. We also discuss a recently described risk factor, present in our patient, as a potential role in the development of pulmonary embolism.

Use of Simulation to Enhance Learning in a Pediatric Elective

To assess the impact on learning of adding a pediatric human patient simulation to a pharmacy course. Pharmacy students enrolled in a pediatric elective participated in 1 inpatient and 1 outpatient scenario using a pediatric patient simulator. Immediately following each case, reflective debriefing occurred. Forty-two students participated in the simulation activity over 2 academic years. A pretest and posttest study design was used, with average scores 4.1 + or - 1.2 out of 9 on pretest and average 7.0 + or - 1.5 out of 9 on posttest (p < 0.0001). Ninety-five percent (40/42) of students' scores improved. Students felt the learning experiences were positive and realistic. Pharmacy students' knowledge and application skills improved through use of pediatric simulation exercises.

Emergency Management and Commonly Encountered Outpatient Scenarios in Patients With Hyperkalemia

Emergency Management and Commonly Encountered Outpatient Scenarios in Patients With Hyperkalemia