The emergency room and the hypertensive patient. Improving linkage to clinical care

The authors evaluated three methods of referring new hypertensive patients from a large municipal hospital emergency room to an ongoing medical care system. A total of 239 patients were assigned to one of three groups. Compliance with recommendations to receive follow-up care was compared for each group. Forty-two percent of patients who received a routine referral from nurses or physicians plus a follow-up telephone call or letter complied. Thirty percent of patients who received a referral from a specially trained interviewer to the hospital's outpatient assessment area complied. These two groups were not significantly different. Compliance was significantly greater (65%, P less than 0.001) for a third group of patients who received an appointment from an interviewer to the outpatient general medicine clinic. The appointment was within 3 days from the time of the emergency room visit. An early appointment intervention given to new high blood pressure patients in the emergency room is recommended to improve patient return for follow-up care, thereby improving linkage to an ongoing care system.     

Homeopathic treatment for chronic disease: a 6-year, university-hospital outpatient observational study

OBJECTIVE: The aim of this study was to assess health changes seen in routine homeopathic care for patients with a wide range of chronic conditions who were referred to a hospital outpatient department. DESIGN: This was an observational study of 6544 consecutive follow-up patients during a 6-year period. SETTING: Hospital outpatient unit within an acute National Health Service (NHS) Teaching Trust in the United Kingdom. PARTICIPANTS: Every patient attending the hospital outpatient unit for a follow-up appointment over the study period was included, commencing with their first follow-up attendance. MAIN OUTCOME MEASURE: Outcomes were based on scores on a 7-point Likert-type scale at the end of the consultation and were assessed as overall outcomes compared to the initial baseline assessments. RESULTS: A total of 6544 consecutive follow-up patients were given outcome scores. Of the patients 70.7% (n = 4627) reported positive health changes, with 50.7% (n = 3318) recording their improvement as better (+2) or much better (+3). CONCLUSIONS: Homeopathic intervention offered positive health changes to a substantial proportion of a large cohort of patients with a wide range of chronic diseases. Additional observational research, including studies using different designs, is necessary for further research development in homeopathy.     

Substitution model with central role for nurse specialist is justified in the care for stable type 2 diabetic outpatients

AIM OF THE STUDY: Assessment of effects on quality of care, in terms of patient outcomes, when tasks in the care for outpatients with stable type 2 diabetes are transferred from internist to nurse specialist and from outpatient clinic to general practice. BACKGROUND: For the management of chronic diseases with a high prevalence and requiring current monitoring, it is suggested that substitution of care may be an appropriate solution to safeguard high quality care. DESIGN AND METHODS: A 12-month nonequivalent control group design was used. General practitioners (GPs) referring diabetes patients to the University Hospital Maastricht were asked to choose for the traditional model or the nurse specialist model. Informed consent was obtained from patients with stable diabetes type 2 attending these practices. All patients received care according to the model chosen by their GP. Identified outcomes were: clinical status, health status, self-care behaviour, knowledge of diabetes, patient satisfaction, and consultation with care-providers. RESULTS: In the control group (n=47) no patients were treated with oral hypoglycaemic agents (OHA) only. The control group was compared with an intervention subgroup (n=52) also without patients receiving OHA only. Clinical data were available for all patients. Patients without complete data from questionnaires had better mean concentration of HbA1c than patients with complete data (P=0.004). The traditional care model and the nurse specialist model achieved equal outcomes, while glycaemic control of patients in the nurse specialist model improved (from 8.6% to 8.3%) but deteriorated in the traditional model (from 8.6% to 8.8%; P-value between groups=0.001). CONCLUSIONS: The model with nurse specialists taking on roles and tasks beyond those traditionally regarded as their remit as well as new ones, is effective for the care of stable diabetic outpatients.     

Clinical management of atrial fibrillation: early interventions,observation, and structured follow-up reduce hospitalizations

Background

Novel facilities such as an intensive observation unit and an outpatient clinic could result in improving management of patients presenting with atrial fibrillation (AF).

Methods

This observational study enrolled 3475 patients. Group 1 (1120 patients; years 2004-2005) was managed with standard approach; group 2 (992 patients; years 2006-2007) was managed with additional intensive observation; group 3 (1363 patients; years 2008-2009) was managed with additional intensive observation and outpatient clinic. Primary end point was admission to hospital. Secondary end points included modalities of rhythm conversion and administration of class IC vs class III antiarrhythmic drugs in patients with AF lasting less than 48 hours.

Results

Lack of rhythm control, comorbidities, diabetes, and age were independent predictors of hospitalization. Admissions significantly decreased from group 1 (50%) to 2 (38%) and to 3 (24%) (P < .001). Interestingly, more than a quarter of patients in group 3 were referred to the outpatient clinic for short-term follow-up, eventually avoiding admission. Patients with AF lasting less than 48 hours (n = 2189) and without structural heart disease (n = 1685) achieved sinus rhythm in 89% of cases and were discharged. In these patients, early administration of antiarrhythmic drugs of class IC and III gained sinus rhythm in 80% and 20%, respectively (P < .001). Spontaneous conversion occurred in 26%; electrical, 17%; and pharmacological, 57%.

Conclusions

In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations. Patients without structural heart disease treated with antiarrhythmic drugs achieved sinus rhythm in 89% of cases, mostly with class IC drugs.     

Communication with referring physicians in a palliative radiotherapy clinic

Goals The rapid response radiotherapy program (RRRP) at Toronto-Sunnybrook Regional Cancer Center (TSRCC) provides quick access to palliative radiotherapy for patients with a life expectancy of less than 12 months. Patients then return to their referring physician for continued oncologic management. After the initial RRRP consultation, we fax an interim consultation report to the referring physician. The purpose of this study was to assess how useful referring physicians perceive this interim report and whether this report needs to be modified to meet their information needs.Methods Physicians who referred patients to the RRRP and who were faxed an interim consultation report were identified over a 4-month period. These physicians were then faxed a questionnaire that asked how useful the interim report was in patient management, about their satisfaction with the information provided, to critique the report format, and whether the RRRP physician and nurse were easily accessible by telephone.Main results Forty physicians referred patients to the RRRP clinic over the 4-month study period. The response rate to our survey was 58% (23/40). The vast majority of physicians (95%) stated that the interim consultation report was useful in patient management. They felt that treatment details were adequately discussed in the report. The report format was perceived to be clear and concise. Referring physicians wished to be informed about any medication changes. RRRP physicians and nurse were perceived to be easily accessible by telephone if needed.Conclusions Results showed that referring physicians found the faxed interim consultation report useful in patient management. Suggestions were made on how to improve the report, and they will be used to further enhance physician communication and ultimately patient care.     

Results of an open-label, prospective study of anticoagulant therapy for atrial fibrillation in an outpatient anticoagulation clinic

OBJECTIVE: The goal of this study was to investigate the complications and control of warfarin treatment in patients with nonvalvular atrial fibrillation (NVAF) newly referred to an outpatient anticoagulation clinic. METHODS: This study included new patients with NVAF who were referred to an anticoagulation clinic for warfarin therapy over a recruitment period of 21 months. To reflect real-world clinical practice, patient selection for anticoagulation and patient management were left to the referring physicians, who were blinded to their patients' participation in the study. Patients were interviewed in person at the first clinic visit and then by telephone every 4 to 6 weeks. They were questioned about any bleeding or thromboembolic events. RESULTS: A total of 402 patients were included (100% of all new referrals over 21 months). The mean (SD) age was 72.3 (10.3) years, and 224 (56%) patients were men. The mean (SD) international normalized ratio (INR) was 2.4 (0.31). Patients were followed up for a mean (SD) of 19 (8.1) months (range, 1.0-31.0 months). They spent a mean (SD) 66% (18.3) of time in the target range of INR (ie, 2.0-3.0). Annual event rates were 1.7% (95% CI, 0.4%-3.0%) for major bleeding, 16.6% (95% CI, 13.0%-20.2%) for minor bleeding, 1.2% (95% CI, 0.1%-2.3%) for ischemic stroke, and 0.3% (95% CI, 0.2%-0.8%) for transient ischemic attacks. There were no cases of hemorrhagic stroke or fatal bleeding. Variability of INR and number of medications were identified as risk factors for bleeding (P = 0.03 and P = 0.001, respectively). There was no significant association between age and bleeding. CONCLUSIONS: Based on this analysis, the risks of long-term oral anticoagulation therapy in an outpatient anticoagulation clinic appear to reflect the results of clinical trials. Rates of ischemic stroke, major bleeding, and anticoagulation control were comparable. There was no age-related risk of complications.     

Ambulatory hysteroscopy in evaluation of postmenopausal bleeding]

INTRODUCTION: Diagnostic hysteroscopy is the most precise procedure to evaluate diseases involving the uterine cavity. There is, however, only limited data concerning the use of hysteroscopy carried out as an outpatient procedure in patients with postmenopausal bleeding. MATERIALS AND METHODS: In this study we report on 360 postmenopausal patients with erratic bleeding, who were referred to our outpatient hysteroscopy clinic. 185 women had frank postmenopausal bleeding (PMB) and another 175 had abnormal uterine bleeding while taking hormone replacement therapy (AUB). The mean age was 57.9 years (range: 42-86). All hysteroscopies were performed using a standard 5-mm hysteroscope with a 30 degrees fore-oblique lens; the uterine cavity was generally distended with normal saline. RESULTS: Outpatient hysteroscopy was performed successfully in 339 patients (94.2%). In 166 cases (46.1%) cervical dilatation was necessary, and 138 required (38.3%) intracervical anaesthesia. Intrauterine pathology was diagnosed in 49.6% of cases, with endometrial polyps (20.9%) and fibroids (15.9%) being the most common abnormalities. While there was no difference in the incidence of intrauterine lesions between patients with AUB and those with PMB, endometrial carcinoma was more common in the latter group (PMB: n = 11 vs. AUB: n = 1; p < 0.002). CONCLUSION: Due to its high accuracy and patient acceptance, outpatient diagnostic hysteroscopy should become a first line investigation in postmenopausal patients with bleeding disorders.     

Characteristics of the first 1000 headaches in an outpatient headache clinic registry

(Headache 2011;51:226‐231) Objective.— To analyze the incidence and characteristics of the first 1000 headaches in an outpatient clinic. Background.— Headache is a common cause of medical consultation, both in primary care and in specialist neurology outpatient clinics. The International Classification of Headache Disorders, 2nd Edition (ICHD‐II), enables headaches to be classified in a precise and reproducible manner. Methods.— In January 2008, an outpatient headache clinic was set up in Hospital Clínico Universitario, a tertiary hospital in Valladolid, Spain. Headaches were classified prospectively in accordance with ICHD‐II criteria. In each case we recorded age and sex, duration of headache, ancillary tests required, and previous symptomatic or prophylactic therapies. Results.— In January 2010, the registry included 1000 headaches in 682 patients. The women/men ratio was 2.46/1 and the mean age of the patients was 43.19 ± 17.1 years (range: 14‐94 years). Patients were referred from primary care (53.4%), general neurology clinics (36.6%), and other specialist clinics (9%). The headaches were grouped (ICHD‐II classification) as follows: group 1 (Migraine), 51.4%; group 2 (Tension‐type headache), 16%; group 3 (Trigeminal autonomic cephalalgias), 2.6%; group 4 (Other primary headaches) and group 13 (Cranial neuralgias), 3.4%. The diagnostic criteria of chronic migraine were satisfied in 8.5% of migraines. Regarding secondary headaches, 1.1% of all cases were included in group 5 (Headaches attributed to trauma) and 8.3% in group 8 (Headaches attributed to a substance or its withdrawal). Only 3.4% of headaches were classified in group 14 (Unspecified or not elsewhere classified), and 5.2% were included in the groups listed in the ICHD‐II research appendix. Conclusion.— This registry outlines the characteristics of patients seen in an outpatient headache clinic in a tertiary hospital; our results are similar to those previously reported for this type of outpatient clinic. Migraine was the most common diagnosis. Most headaches can be classified using ICHD‐II criteria.     

Missed Opportunities of Integration of Palliative Care: Frequency,Causes, and Profile of Missed Visits in an Oncologic Palliative Care Outpatient Unit

ContextMany patients with cancer are referred to palliative care (PC) outpatient clinics but do not attend consultations, which increases the difficultly of integrating PC in a timely manner.ObjectivesTo evaluate the frequency, causes, and profile of missing first-time consultations in a PC outpatient clinic.MethodsData from patients with advanced cancer who were scheduled for first-time visits to the PC outpatient clinic from September 2018 to August 2019 were analyzed. Missed consultation was defined as a nonperformed consultation with no prior notice of cancellation, and missed opportunity of palliative care (MOPC) was defined as a nonperformed consultation regardless of being notified in advance. The causes of the absence were identified by telephone using a standardized form. Logistic regression models were used to identify the profile of patients who have MOPC.ResultsAbout 1468 patients were scheduled for first-time visits to the PC outpatient clinic; missed consultation = 21.7% (n = 275) and MOPC = 32.5% (n = 478). Of the total number of patients who had MOPC, 86 (18%) were later seen in a median time (percentile p25–p75) of 29.5 days (range 7.0–66.5). The most common cause of MOPC was death before consultation (n = 92; 29.8%). Referral to PC using a standardized protocol (odds ratio 0.787; P = 0.044) and residence in distant cities (odds ratio 2.394; P < 0.001) were independently associated with MOPC.ConclusionApproximately one-third of patients eligible for PC miss the opportunity to be included earlier; only 18% of them are consulted later. Use of standardized referral protocols may help to reduce these absence rates.     

Trigger factors of migraine and tension-type headache: experience and knowledge of the patients

The objective was to examine potential trigger factors of migraine and tension-type headache (TTH) in clinic patients and in subjects from the population and to compare the patients’ personal experience with their theoretical knowledge. A cross-sectional study was carried out in a headache centre. There were 120 subjects comprising 66 patients with migraine and 22 with TTH from a headache outpatient clinic and 32 persons with headache (migraine or TTH) from the population. A semistructured interview covering biographic data, lifestyle, medical history, headache characteristics and 25 potential trigger factors differentiating between the patients’ personal experience and their theoretical knowledge was used. The most common trigger factors experienced by the patients were weather (82.5%), stress (66.7%), menstruation (51.4%) and relaxation after stress (50%). The vast majority of triggers occurred occasionally and not consistently. The patients experienced 8.9±4.3 trigger factors (range 0–20) and they knew 13.2±6.0 (range 1–27). The number of experienced triggers was smallest in the population group (p=0.002), whereas the number of triggers known did not differ in the three study groups. Comparing theoretical knowledge with personal experience showed the largest differences for oral contraceptives (65.0 vs. 14.7%, p<0.001), chocolate (61.7 vs. 14.3%, p>0.001) and cheese (52.5 vs. 8.4%, p<0.001). In conclusion, almost all trigger factors are experienced occasionally and not consistently by the majority of patients. Subjects from the population experience trigger factors less often than clinic patients. The difference between theoretical knowledge and personal experience is largest for oral contraceptives, chocolate and cheese.     

What do patients expect from their first visit to a pain clinic?

OBJECTIVE: To examine patients' expectations of their first outpatient visit to a pain clinic. We asked patients what would be the most satisfying and the most disappointing outcomes of their visit and whether they expected changes in medication and further investigations to result from their consultation. DESIGN: Patients completed questionnaires and a structured interview to assess expectations before their clinic appointment. METHODS: Seventy-seven patients with chronic pain who were first time referrals to a regional pain clinic participated in the study. Patient expectations and questionnaires measuring depression and pain-related disability were completed prior to the pain clinic appointment. RESULTS: Most patients expected an explanation or an improved understanding of their pain problem. The most common satisfying outcome was relief or control of pain, and the most common disappointing outcome was being told nothing could be done. The majority of patients expected further medical investigations and changes to the prescribed medication. Depression and pain-related disability strongly influenced patient expectations. CONCLUSIONS: For patients attending pain clinics, the explanation of their pain problem is rated as important as the cure or relief of their pain. Improved understanding of patient expectations by pain clinic clinicians may lead to greater patient satisfaction and reduced treatment dropout.     

Evaluating a nurse-led DXA scanning service

AIM: To examine the feasibility of using a peripheral dual energy X-ray absorptiometry (DXA) scanning service in a nurse-led clinic and whether or not it would influence treatment and clinician satisfaction with the service. METHOD: A nurse-led clinic, using peripheral DXA scans to identify patients at risk of osteoporosis, was established in the rheumatology department of the hospital. Patients were referred from several sources. A questionnaire was sent to referring health professionals with each scan result. Returned questionnaires were statistically analysed. Of the sample size of 2000, 1024 questionnaires were returned, giving a response rate of 51 per cent. RESULTS: The results confirmed the hypothesis that a nurse-led peripheral DXA scanning service is feasible and beneficial to referring clinicians. Eighty nine per cent (n=912) of respondents stated that the scan results influenced treatment of patients. CONCLUSION: Further investigation of the extent that the DXA scanning service may have reduced unnecessary treatment is required.     

卒中健康管理门诊的建立与实践效果研究

目的探讨开展卒中健康管理门诊的效果。方法便利抽样法选取2018年11月至2019年5月上海市某三级甲等医院收治的脑卒中患者288例为研究对象,按其住院号末位数字的奇偶数分为门诊管理组和电话随访组。电话随访组给予常规电话随访,门诊管理组通过卒中健康管理门诊就诊.健康管理师根据患者住院期间建立的健康管理档案,评估患者高危因素的管控情况,提供专业健康管理服务。比较两组患者疾病知识掌握、自我行为管理、复诊率、服药依从性及卒中合并症(高血压和高血糖)的发生情况及卒中复发率。结果门诊管理组疾病知识掌握、自我行为管理、复诊率均优于电话随访组,合并.症发生情况及卒中复发率低于电话随访组,差异均有统计学意义(均P<0.05)。结论开展卒中健康管理门诊能提高患者疾病知识掌握程度、复诊率,改善患者自我行为管理能力.提高服药依从性及降低合并症的发生,从而降低卒中复发风险。     

Do patients want copies of their GP letters? – our experience with 7250 patients

A prospective study was performed to investigate whether patients would actively request a copy of their GP letters following an outpatient consultation. The study was performed at two sites and involved 7250 Trauma & Orthopaedic patients, and of these only 0.3% of patients requested a copy of their letter by actively filling in a stamped envelope. The estimated cost of sending a copy of the letter to all the patients seen in the NHS Outpatients was 13 million pounds in England alone. We suggest that rather than sending patients' copies of all their correspondence as a routine, there are more secure and cost effective ways to inform patients and allow free access to all information recorded in their medical notes.     

The effect of telephone appointment-reminder calls on outpatient absenteeism in a pulmonary function laboratory

BACKGROUND: Absenteeism from outpatient appointments is common. Telephone appointment-reminder calls reduce outpatient-appointment absenteeism in many clinic settings. OBJECTIVE: To determine if telephone appointment-reminder calls reduce outpatient absenteeism at a hospital-based pulmonary function laboratory. METHODS: We conducted a retrospective review of our pulmonary function laboratory's outpatient appointment records from April to November 2004. Data were collected from consecutive outpatient appointments, including patient age, sex, whether a telephone appointment-reminder call was successfully made, and whether the patient showed up for the scheduled test. We performed 3 analyses. Differences in absenteeism between the groups was the primary outcome measure. First, appointments were separated into 2 groups: (1) appointments for which a reminder call was attempted ("called" group) and (2) appointments for which a reminder call was not attempted ("not-called" group). The appointments were then separated into 2 further groups: (1) the reminder call was successfully achieved ("contacted" group) and (2) the patient either was not called or was called but could not be reached ("not-contacted" group). Finally, the contacted group was separated into 2 further groups: (1) reminder calls that resulted in direct conversation with an appropriate person at the patient's listed telephone number, and (2) reminder message left on an answering machine. RESULTS: Data were collected from 515 consecutive outpatient appointments; 45 (8.7%) of these patients did not show up for testing. The absentee rate was 4.7% (n = 10) in the called group and 11.6% (n = 35) in the not-called group (p = 0.0066). In the called group, 6.5% (n = 14) could not be reached. The absentee rate was 4% (n = 8) in the contacted group and 11.7% (n = 37) in the not-contacted group (p = 0.0021). We found no difference in absenteeism between patients who received reminders via direct conversation (4.2%) and those who had a reminder message left on an answering machine (3.7%) (p > 0.05). CONCLUSIONS: A policy of reminding outpatients of their appointments via telephone reduces absenteeism at a hospital-based pulmonary function laboratory. We found no difference in absenteeism between communicating the reminder via direct conversation versus via leaving a message on an answering machine.     

Classification of reasons for consultation and results of consultation in a selected sample from specialized pulmonary outpatient care

According to Braun's theory of applied medicine terminology 4 results of medical consultation can be defined: A) classification of symptoms, B) classification of groups of symptoms, C) classification of the clinical picture, and D) exact diagnosis. In general practice only about 10% of the results of medical consultation are exact diagnoses. We wondered if the categories A-D also pertain to the patients of a specialized pulmonary diseases outpatient department. 20 consecutive new patients were studied who had been referred by other outpatient departments, consultant specialists, or general practitioners. The group consisted of 13 men and 7 women, mean age 40 years, range 18 to 65 years. In 9 patients consultation resulted in an increase in differentiation by one or two stages in comparison with the reason for referral. The result of consultation was not an exact diagnosis, in 10 cases, even in a specialized outpatient department. Thus, Braun's terminology of applied medicine with respect to the reason for, and the result of a medical consultation is generally valid, as shown by application to a specialist outpatient department.     

特需门诊患者护理服务需求的调查及对策

目的了解不同层次特需门诊患者对护理服务的需求,从而采取针对性的措施,进一步优化特需门诊的服务流程,提升护理服务质量和患者满意度。方法采用方便抽样法选择2009年1月来特需门诊就诊的100例患者设为护理服务改进前组,自行设计调查问卷对其进行护理服务满意度调查,以了解其对护理服务的需求,并针对调查结果改进相关环节;选择2009年6月来特需门诊就诊的100例患者设为护理服务改进后组,采用同样的问卷进行调查。比较护理服务改进前后两组患者的满意度差异。结果护理服务改进后,患者对特需门诊的就诊环境、就诊流程、检查项目指导、保护个人隐私以及健康教育等服务项目满意的例数及百分率显著提高,不满意的例数及百分率显著降低,差异有统计学意义（均P〈0.05）。结论温馨舒适的就诊环境是满足特需患者护理服务需求的关键,方便快捷的就诊流程是提高患者满意度的基本保证,针对检查项目而采取的指导、保护个人隐私和个性化的健康教育等人性化服务措施是满足特需门诊患者护理服务需求的重要手段。     

助产咨询门诊对孕妇分娩方式选择的影响

目的探讨助产咨询门诊对孕妇分娩方式选择的影响。方法选择在我院产科门诊进行产检的孕妇200例,随机分为对照组与干预组各100例,对照组采用常规产前健康教育,干预组在此基础上参加助产咨询门诊举办的分娩学习班,实施个体化心理干预,比较2组孕妇干预前后对分娩方式的选择。结果2组孕妇干预前对分娩方式选择的比较,差异无统计学意义（P〉0．05）;干预后2组患者对分娩方式选择的比较,差异有统计学意义（P〈0．01）。结论助产咨询门诊,让孕妇对分娩和分娩过程中有一个正确的认识,掌握分娩应对技能,有效减少社会因素导致的剖宫产,促进顺产分娩率,提高分娩质量。