Primary care safety-net delivery sites in the United States: A comparison of community health centers, hospital outpatient departments, and physicians' offices

CONTEXT: The US primary care safety net is composed of a loose network of community health centers, hospital outpatient departments, and physicians' offices. National data on how the mix of patients and services differ across sites are needed. OBJECTIVE: To develop and contrast national profiles of patient and service mix for primary care. DESIGN, SETTING, AND PATIENTS: Comparative analyses of 3 national surveys of primary care visits occurring in 1994: for data on physician's office visits, the National Ambulatory Medical Care Survey (NAMCS); for hospital outpatient department data, the National Hospital Ambulatory Medical Care Survey (NHAMCS); and for data on community health centers, the Bureau of Primary Health Care's 1994 Survey of Visits to Community Health Centers. A time trend analysis also was conducted using the 1998 NAMCS and NHAMCS. MAIN OUTCOME MEASURES: National estimates of primary care visit rates, types of patient presentation, patient case-mix, disposition of patients, and management interventions in 1994, and compared with 1998 data. RESULTS: The US population made 1.3 primary care visits per person in 1994, which accounted for 43.5% of all ambulatory visits to physicians' offices, community health centers, and hospital outpatient departments. Primary care visits per person were 20% lower for Hispanics and 33% lower for black, non-Hispanic persons compared with white, non-Hispanic persons. Visits to community health centers were more likely to be made by ethnic minorities, patients with Medicaid or no insurance, and rural dwellers than visits made to the other delivery sites. Visits at hospital outpatient departments were made by sicker populations and were characterized by less continuity than the other delivery sites. Controlling for patient mix, visits made to hospital outpatient departments were more commonly associated with imaging studies, minor surgery, and specialty referrals than those made to physicians' offices. In 1998, the US population made an estimated 3. 4 visits per person, 45.6% of which were primary care visits. National estimates of primary care visit rates and patient mix and practice pattern comparisons between hospital outpatient departments and physicians' offices were similar in 1998 and 1994. CONCLUSIONS: Expanding community health centers will likely improve access to primary care for vulnerable US populations. However, enhancing access to of physicians' offices is also needed to bolster the safety net. The greater service intensity and poorer continuity for primary care visits in hospital outpatient departments that we observed raises concern about the suitability of these clinics as primary care delivery sites. JAMA. 2000;284:2077-2083.     

The effect of outpatient visit volume on inpatient teaching services

Ambulatory clinics at public teaching institutions often have less potential for generating revenues than the inpatient services. In times of fiscal constraint, they are, therefore, vulnerable targets for cutbacks in services. A financial crisis in the Bexar County Hospital District led to administrative changes which caused a 20 percent decline in outpatient visits for the entire year. This resulted in a 10 percent fall in the inpatient census and adverse effects on teaching programs and on hospital finances. A regression of inpatient activity with outpatient activity showed a highly significant correlation (r = .57, p less than .01). The decline in the inpatient census contributed to a renewed institutional commitment to ambulatory services. In addition to their direct role in patient care and training, the outpatient clinics thus appear to be essential to the success of inpatient teaching programs. These data emphasize the importance of "vertical integration" (that is, ownership of facilities providing several levels of care) of services to the survival of academic health centers.     

Pocket book of hospital care for children

This pocket book is for use by doctors, senior nurses and other senior health workers who are responsible for the care of young children at the first referral level in developing countries. It presents up-to-date clinical guidelines which are based on a review of the available published evidence by subject experts, for both inpatient and outpatient care in small hospitals where basic laboratory facilities and essential drugs and inexpensive medicines are available. In some settings, these guid…     

Hospital ownership and psychiatric services

Dramatic increases have occurred in the proportion of for-profit hospitals in the general hospital sector; even more pronounced increases have occurred within the psychiatric sector. Concomitant with this changing mix of ownerships, revised reimbursement plans are being proposed for psychiatry. Thus, providers of acute psychiatric inpatient care, although loosely aggregated, constitute a service system that is experiencing dynamic revision. This article examines the implications of these changes for health policy analysts and planners in the design of hospital payment mechanisms and in planning for resources to meet the needs of the public. The state of California is viewed as a system, and data from the state are examined to test traditional assumptions of economic behavior when less costly substitute services are available. The availability of services such as outpatient clinics, emergency psychiatric services, and partial hospitalization are found to vary according to hospital ownership. Differences in availability of these services influence the access to inpatient care experienced by various populations within the defined system. Although these services may permit earlier discharge from the hospital, the poor insurance coverage of ambulatory psychiatric care relative to inpatient hospitalization^1–3 distorts this effect. The implications of these findings for public policy are discussed.     

基层医疗卫生机构设置发热哨点诊室的建议与思考

基层医疗卫生机构在突发公共卫生事件应急网络中起到“网底”的作用。在基层医疗卫生机构设置发热哨点诊室有利于实现突发公共卫生事件和发热诊室“早发现、早诊断、早隔离和及时上报”,从而控制疫情进展。目前,我国正在加紧基层医疗卫生机构发热哨点诊室的建设,对其建设标准和职能有了初步的规定。根据相关文件要求,基层医疗卫生机构发热哨点诊室的最低标准应包括建设布局、硬件和软件配置三方面的内容,针对目前基层医疗卫生机构普遍存在的问题,应加强社区卫生应急体系建设、广泛开展人员培训与工作督导、建设便捷通畅的信息网络,规范建设发热哨点诊室并实施持续性运行管理,才能有效发挥发热哨点诊室的作用,使之在公共卫生事件应急体系中发挥重要的“网底”作用。     

Trends in user-initiated health information exchange in the inpatient,outpatient, and emergency settings

Prior research on health information exchange (HIE) typically measured provider usage through surveys or they summarized the availability of HIE services in a healthcare organization. Few studies utilized user log files. Using HIE access log files, we measured HIE use in real-world clinical settings over a 7-year period (2011-2017). Use of HIE increased in inpatient, outpatient, and emergency department (ED) settings. Further, while extant literature has generally viewed the ED as the most relevant setting for HIE, the greatest change in HIE use was observed in the inpatient setting, followed by the ED setting and then the outpatient setting. Our findings suggest that in addition to federal incentives, the implementation of features that address barriers to access (eg, Single Sign On), as well as value-added services (eg, interoperability with external data sources), may be related to the growth in user-initiated HIE.     

Appropriateness in health care delivery: definitions, measurement and policy implications.

A major focus of the current health care debate is the notion that a substantial proportion of the health care delivered in Canada is inappropriate. There are two types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided (i.e., inpatient v. outpatient or home care). Measuring both types objectively requires the comparison of observed patterns of care with explicit criteria for appropriate care. The few studies of appropriateness conducted in Canada have shown that inappropriate services are provided and inappropriate settings are used. Reducing inappropriate health care delivery could involve active strategies for the implementation of guidelines and better cooperation and coordination within the health care system. However, lower rates of health care delivery or even inappropriate health care will not necessarily translate into higher quality care or lower costs overall.     

Assessment of dermatologists’ perception of utilizing teledermatology during COVID-19 pandemic in Saudi Arabia

Objectives:To assess teledermatology (TD) perception among dermatologists in the Kingdom of Saudi Arabia during the COVID-19 pandemic and to identify the most common advantages and disadvantages of TD.Methods:We conducted a cross-sectional survey-based study to address Saudi dermatologist perceptions of TD from July 2020 to December 2020, during Covid-19 pandemic.Results:Out of 664 emails sent, 107 complete responses were returned. Approximately 40.2% used TD through phone calls, followed by those who used a virtual clinic (32.7%). Also, the best way to use TD, according to respondents, was for triage before inpatient and outpatient visits. When we compared the use of TD in the outpatient and inpatient settings, outpatient responses always had more positive attitudes than inpatients. The most important benefit of TD is to reduce the risk of pandemic infections (69%). More than half of the participants sometimes used TD for diagnosis (n=63, 58.9%) and management (n=59, 55.1%), and 69 (64.5%) considered using it in the future.Conclusion:Our survey-based study indicates that TD is an important part in the future dermatology because our participants agreed that TD decreases cost, increases access to dermatology care, and reduces the risk of pandemic infections. And it is necessary to establish an infrastructure for TD that protects patient’s privacy and ensures accurate diagnosis.     

MRSA infections in children

MRSA infections continue to be a serious and formidable challenge to health care providers and their prevalence is increasing exponentially. In the past, MRSA infections were observed only in hospitalized patients whereas now they are encountered in the outpatient setting. Understanding the pattern of the widespread distribution of MRSA as well as the factors associated with its spread are paramount to its recognition and eradication. The current state of MRSA transmission, control and management is reviewed.     

Supporting the health care team in caring for patients with AIDS

A multidisciplinary approach to AIDS health care is described that combines skilled generalists with subspecialists in oncology and infectious disease; incorporates assistance with the social, economic, and psychological sequelae of AIDS; and taps the resources available in the patient's community to staff inpatient and outpatient clinics. Many unresolved ethical issues posed by AIDS and the stresses of AIDS care are explored. The distribution of patients with AIDS as widely as possible throughout the physician community, publication of a newsletter of practical AIDS information, participation of staff members in decision making and formation of program goals, and collaboration with therapists have helped to reduce the stress of AIDS clinic staff members at the San Francisco General Hospital.     

东莞市社区门诊首诊制的运行现状调查

社区首诊制是分级诊疗制度的核心问题,东莞市自2008年开始实施社区门诊首诊制,现已取得一定成效。本文旨在对其运行现状进行分析,结果显示,2009—2016年东莞市社区门诊结算人次逐年递增,有效缓解了居民“看病难、看病贵”问题,有利于对慢性病的预防保健管理,同时兼顾了卫生服务的公平和效率。但在运行过程中,仍存在各镇（街）发展差异大、转诊手续繁琐、转诊率高、人才招聘和稳定性不足等问题。建议统一社区卫生服务中心的建立标准、规范社区门诊转诊标准、建立科学的薪酬体系和晋升机制,同时引导居民转变就医观念,以推动社区门诊首诊制的持续发展。     

Outpatient preanaesthesia evaluation clinics

In recent years, there has been a paradigm shift from an inpatient to outpatient preanaesthesia evaluation. This has been driven by rising healthcare costs and the increasing popularity of ambulatory and same-day admission surgery. These outpatient preanaesthesia clinics play an important role in enhancing the cost-effectiveness of the perioperative process. This review describes the structure of modern outpatient preanaesthesia evaluation clinics, and the associated benefits, limitations and controversies.     

在综合医院精神科门诊对进修全科医师骨干临床教学的实践体会

对全科医师骨干进行精神科培训可以促进精神疾病的二级预防,节约医疗资源和社会成本,提高患者的生活质量。在综合医院精神科门诊对全科医师骨干的带教过程中,要通过重视入科教育、开展心理卫生讲座、门诊和住院病例分析、培养循证医学和科研思维、培养人文关怀能力,以及角色扮演考试的方法提高了全科医师骨干的培训质量。     

National surveillance of AIDS in health care workers

Information obtained for all persons with the acquired immunodeficiency syndrome (AIDS) reported to the Centers for Disease Control, Atlanta, includes a question about employment in a health care or clinical laboratory setting. As of May 1, 1986, a total of 922 (5.5%) of 16,748 adults with AIDS reported employment in such settings. Ninety-five percent of these health care workers belonged to recognized high-risk groups for AIDS; the proportion with "no identified risk" has not increased with time. All AIDS patients (including health care workers) who do not belong to high-risk groups are referred for further investigation. Of 88 health care workers initially reported with no identified risk, ten were from countries where heterosexual transmission is believed to play a major role; additional information was unobtainable or incomplete for 17 individuals. Of 61 persons on whom interviews or other follow-up information was obtained, 44 (73%) were reclassified. Specific occupational exposures that could be implicated as the source of human immunodeficiency virus infection were not identified for any health care workers with AIDS. A review of surveillance data supports other studies indicating that the risk of human immunodeficiency virus transmission in the occupational setting is low.     

Management of hypertensive emergencies in children

Pediatric hypertension is considered a relatively recent disease. Most hypertensive children do not require emergent care and can be managed in an outpatient setting. On the other hand, hypertensive emergencies and urgencies which can be encountered in the outpatient clinics, the inpatient wards or during an emergency visit need prompt recognition and treatment. Efficient management of these children is essential to avoid some of the life-threatening complications associated with hypertension and its treatment. This article will focus on the main pharmacologic agents used in the management of hypertensive emergencies in the pediatric population.     

Postgraduate training for general practice in the United Kingdom.

Although the role of general practice is well established in the United Kingdom's National Health Service, formal postgraduate training for primary care practice is a recent development. Trainees may enter three-year programs of coordinated inpatient and outpatient training or may select a series of independent posts. Programs have been developed to train general practitioners as teachers, and innovative courses have been established. Nevertheless, there is a curious emphasis on inpatient experiences, especially since British general practitioners seldom treat patients in the hospital. In their outpatient experiences trainees are provided with little variety in their instructors, practice settings, and medical problems. The demands on this already strained system will soon be increased due to recent legislation requiring postgraduate training for all new general practitioners. With a better understanding of training for primary care in the National Health Service, those planning American primary care training may avoid the problems and incorporate the attributes of British training for general practice.     

Evaluation and Certification of Computerized Provider Order Entry Systems

Computerized physician order entry (CPOE) is an application that is used to electronically write physician orders either in the hospital or in the outpatient setting. It is used in about 15% of U.S. Hospitals and a smaller percentage of ambulatory clinics. It is linked with clinical decision support, which provides much of the value of implementing it. A number of studies have assessed the impact of CPOE with respect to a variety of parameters, including costs of care, medication safety, use of guidelines or protocols, and other measures of the effectiveness or quality of care. Most of these studies have been undertaken at CPOE exemplar sites with homegrown clinical information systems. With the increasing implementation of commercial CPOE systems in various settings of care has come evidence that some implementation approaches may not achieve previously published results or may actually cause new errors or even harm. This has lead to new initiatives to evaluate CPOE systems, which have been undertaken by both vendors and other groups who evaluate vendors, focused on CPOE vendor capabilities and effective approaches to implementation that can achieve benefits seen in published studies. In addition, an electronic health record (EHR) vendor certification process is ongoing under the province of the Certification Commission for Health Information Technology (CCHIT) (which includes CPOE) that will affect the purchase and use of these applications by hospitals and clinics and their participation in public and private health insurance programs. Large employers have also joined this focus by developing flight simulation tools to evaluate the capabilities of these CPOE systems once implemented, potentially linking the results of such programs to reimbursement through pay for performance programs. The increasing role of CPOE systems in health care has invited much more scrutiny about the effectiveness of these systems in actual practice which has the potential to improve their ultimate performance.     

Vegemite and chocolate sprinkles: Dutch medical students in rural Australia

The Primary Health Care (PHC) working group of the Department of General Practice of Maastricht University in the Netherlands was founded in 1998 specifically to introduce students to patient care, research and education in primary health care settings outside the Netherlands. Rural health care in Australia is appealing to international medical students because of its unique setting. In the past 5 years, 42 medical students from Maastricht University have pursued a medical elective in rural Australia, supervised by the PHC working group. Doctors and coordinators in primary care clinics across Australia have welcomed and supervised students from Maastricht and exposed them to the reality of rural health care. Future collaboration with other Australian primary care clinics is welcomed.     

Quality of care in hospital emergency departments and family physicians'' offices.

Indicator conditions were used to evaluate the quality of 686 episodes of care provided in two emergency departments and in five family physicians' offices. Overall, the care was considered adequate in 53% of the emergency department cases and in 40% of the cases dealt with in family physicians' offices, the difference being significant (P less than 0.01). Referrals were very common in both settings, and when quality was assessed solely on the basis of the care actually given by the primary-care providers the difference between the two settings disappeared. Half the observed deficiencies in care related to failure to document the findings from history-taking and physical examination. From these and earlier findings we conclude that the emergency department can be an appropriate setting for the care of nontraumatic illness.