Reduction In Clinic Visits Research Articles

Use of a remote telemonitoring platform significantly improves medication optimisation in heart failure patients

Abstract Background Guideline directed medical therapy (GDMT) has been shown to reduce morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). Despite this, a large number of eligible patients do not receive these treatments or have prolonged delays in achieving optimal doses. Purpose To determine whether a telemonitoring-supported, remote medication optimisation programme could increase the proportion of HFrEF patients reaching maximum tolerated GDMT, in a shorter period of time compared to usual care. Methods A prospective, randomised controlled trial recruited 108 patients with a diagnosis of HFrEF from the ambulatory heart function clinic of a North American cardiac centre. All patients were enrolled onto a non-invasive remote monitoring platform which allowed daily nurse coordinator-led assessment of patient-reported symptoms and trends in heart rate, blood pressure and weight. In the remote titration intervention group, telemonitoring data were used by treating physicians to make decisions on optimisation of GDMT every two weeks, which was enacted by the patient's nurse coordinator, with no physician visit required. Patients in the control group were reviewed in clinic by their treating physician, where medication doses were optimised as per standard of care. The proportion of patients achieving maximum tolerated GDMT, and the time taken for this were compared between groups. Continuous data are presented as mean±standard deviation and compared with Student's t-test, while categorical data are shown as number (%) and compared using the Chi-squared test. Results 108 patients (69.4% male, mean age 54.1±15.4 years) were recruited with a median follow-up of 740 days. Baseline characteristics and medication prescription were similar between groups (56 randomised to remote titration, RT, 52 to usual care, UC, see Table). There were three withdrawals from the RT group and two from the UC group. Significantly more patients in the RT group 52/53 (98.1%) achieved the primary outcome, reaching maximum tolerated GDMT, compared with 42/50 (84.0%) in the UC group (p=0.01). The RT group achieved GDMT earlier (123±70 vs. 183±136 days, p=0.01) with a 40% reduction in clinic visits (p<0.01). In a time-to-event analysis, time to optimisation was significantly shorter in the intervention group (median 105 vs. 165 days, p[log rank] <0.01, see Figure). There was a similar increase in prescription of GDMT in both groups and no differences in hospitalisation or urgent clinic review suggesting that there was no excess hazard of remote titration. Conclusion Remote titration of GDMT in HFrEF patients resulted in more patients achieving maximum tolerated doses, on average two months earlier, with a reduction in clinic visits and no excess adverse outcomes. Telemonitoring-supported remote GDMT titration is effective, safe and could reduce healthcare costs associated with the management of HFrEF. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): DHB is supported by a post-doctoral fellowship award from TRANSFORM-HF (Ontario, Canada).

Neck lump clinic: a new initiative at North Shore Hospital.

Neck lumps can cause significant patient anxiety and benefit from a multidisciplinary diagnostic approach, with an ultrasound scan and fine needle aspirate. Internationally, 'one-stop' clinics are used for the evaluation of neck lumps, to date no such clinic has been established in the New Zealand public hospital system. The objective of this study was to demonstrate the feasibility of a one-stop diagnostic neck lump clinic (NLC), aiming for improved patient experience and efficiency. A consultant-led pilot NLC was instituted with the involvement of a head and neck surgeon, radiologist and pathologist, allowing ultrasound scan and fine needle aspirate investigations to be performed simultaneously. A retrospective audit of patients in the 12 months prior to commencement of the NLC provided a comparison group. The median number of clinic visits was 2 in the control group and 1 in the NLC (P < 0.001). Time from first specialist appointment to surgery was 192 days compared to 134.5 days for NLC (P = 0.057). Median time from first specialist appointment to treatment decision was 108.5 days compared to 0 days in the NLC (P < 0.001). Eighty-eight percent of patients in the NLC were given a diagnosis at their first appointment. The median number of investigations required was 2 in the control group and 1 in the NLC (P < 0.001). Median cost per patient in the NLC was $794 and $1470 in the control group. This pilot trial demonstrates streamlined decision-making and efficient utilization of services with a reduction in clinic visits, investigations and cost. High patient satisfaction was reported with this service.

Nuevo modelo de autogestión profesional en atención primaria

ObjectiveTo analyse the benefits of a new organisational model in Primary Care based on the empowerment of professional management compared to standard model (team led by medical director). To improve the quality of care, and patient and professional satisfaction. Material and methodsIn February 2009 six family physician (FP) and four administrative staff met to create a self-management group to care for the 10,281 population assigned to them. The total catchment population of the Primary Care (PC) centre was 32,318. Additionally, between March and December 2010 three FP, seven nurses and two administrative staff, were included in the self-management group making the total population served by the self-management group of 16,368, compared to 15,950 patients seen using the standard model. The model gave priority to self–demand management, professional self-coverage, to reduce clinic bureaucracy, greater efficiency and participation in research and teaching. Results1) Milestone in Pilot Phase (December-2008 to December-2009): increase in attended population, reduction in clinic visits, significant reduction in delay to be visited by a doctor; significant reduction of complementary tests (x-rays, laboratory tests); increase in use of generic drugs and reduction of expensive and new drugs without added value, and active participation in teaching and clinical trials. 2) Consolidation Phase (December-2010, compared to other professionals working in a standard model in the same centre): self-management group reported a lower percentage of clinic visits and a higher percentage of visits resolved through telephoning the clinic. Furthermore, the self-management group achieved better financial results than the control group (additional medical tests, pharmacy budget). The self-management group had improved job satisfaction compared to control group (measured by Professional Questionnaire QoL-35). ConclusionsThe new model has increased professional satisfaction and may improve results in some health indicators (accessibility, efficiency, pharmacy budget) compared with the usual clinical practice.

Change in location of a student health service: a quasi-experimental evaluation of the effects of distance on utilization.

The change to a more distant location of the University of Rochester Student Health Service provided an opportunity for a quasi-experimental evaluation of the effects of distance on utilization. Previous research has used cross–sectional data and provides a hazardous basis for predicting the effects of changes in facility location on utilization. A significant reduction in clinic visits resulted that could not be accounted for by a trend over time. No appreciable changes occurred in utilization of the infirmary whose location remained unchanged. Utilization for respiratory complaints and immunizations seemed to be more affected by the move than were more specialized services. These findings tend to support those of previous cross-sectional studies and illustrate some dilemmas involved in planning the spatial organization of health services.