监护仪血压参数准确性的讨论

本文介绍了血压的溯源、设计原理、引起测量值误差的原因，分析了监护仪血压测量的准确性问题，并提出相应策略。     

Computer networking in an ambulatory health care setting

Computers are a ubiquitous part of the ambulatory health care environment. Although stand-alone computers may be adequate for a small practice, networked computers can create much more powerful and cost-effective computerized systems. Local area networks allow groups of computers to share peripheral devices and computerized information within an office or cluster of offices. Wide area networks allow computers to securely share devices and information across a large geographical area. Either singly or in combination, these networks can be used to create robust systems to help physicians automate their practices and improve their access to important clinical information. In this article, we will examine common network configurations, explain how they function, and provide examples of real-world implementations of networking technology in health care.     

Assessing immunization rates in an ambulatory care setting

Members of the Collaborative Immunization Initiatives determined the immunization coverage rates for two groups of children in our clinic: those 7 to 12 months old and those 18 to 23 months old. The Clinic Assessment Software Application from the Centers for Disease Control and Prevention was used. The immunization rates determined by this method appeared to significantly underestimate the vaccination coverage rates in our clinic. A review of available charts included in the original sample was done excluding patients no longer attending our clinic. We found a higher rate of coverage in the same sample and a low rate of missed opportunities for administering immunizations. The major reason for this discrepancy is overly stringent Clinic Assessment Software Application inclusion criteria. Additional factors include failure to take into account the wide range of acceptable ages for administering immunizations and different dosages for different brands of vaccines. Different methods of calculation may cause as much as a 20% difference in immunization rates for the same or similar population groups. Such large differences may lead to vastly different responses and interventions. We believe that a central registry is the most accurate method of determining immunization rates. Until this is widely available and applied, a more accurate measure of a facility’s immunization effectiveness is the number of missed opportunities for administering immunizations.     

Patients'' therapeutic preferences in an ambulatory care setting

One thousand two hundred-fifteen adult outpatients of an urban health maintenance organization completed questionnaires containing four hypothetical clinical situations. Of these patients, 72 per cent preferred a non-drug "home remedy" when given a choice among that and two different drug options. Risk aversion and willingness to accept current discomfort were stronger than demographic variables in predicting this preference. We conclude that patients informed about the risks and benefits of drug and non-drug therapies will prefer the latter if that option is offered.     

The case for a code of ethics in an ambulatory care setting

The health care industry leads others in the development and use of professional codes of ethics. However, ambulatory care facilities continue to operate without coherent ethical guidelines addressing the workplace itself. New diagnostic and treatment capabilities, coupled with economic pressures, have intensified the ethical dilemmas facing the ambulatory care practice. This article argues that office codes of ethics decrease the risk of liability exposure, clarify the expectations of patients and staff, and foster responsible ethical reflection in the workplace. Material for this article was gathered from relevant literature in the areas of business ethics, bioethics, and health care management.     

Patient judgment of the quality of ambulatory care in a Japanese setting

OBJECTIVE: To assess patient satisfaction with a hospital-based ambulatory service in Japan and define the determinants of satisfaction and the patient's intention to return to the service. DESIGN: A questionnaire was developed to measure overall satisfaction, intention to return to the service, patient judgment about the structure/process of the service, patient perception about the global reputation of the service, and other health-related items. The questionnaire was mailed to patients attending the ambulatory service. SETTING AND PATIENTS: All non-psychiatric patients who used the ambulatory service of a 350-bed general hospital in Tokyo in the sampling days were asked to participate. The response rate was 77.2% (1,307 responses). Of these, 1,074 non-proxy and non pediatric responses were used for the main analysis. RESULTS: Based on content analysis and factor analysis, scores for the service components were constructed and found to have high internal consistency and reliability. The results indicated several important points regarding the use of patients' evaluation of ambulatory services as a quality monitoring tool. It was shown that patients' overall satisfaction and intention to return to the same physician were determined primarily by their evaluation of their doctor's conduct and their perceived health outcome. The perceived reputation of the service also was a significant determinant of patient satisfaction and intention to return. Patient satisfaction and intention to return to the hospital were influenced also by non-physician factors such as nurses, clerks, and environmental comforts. Notably, patient intention to return was linked with patient perceived need of care and regularity of care. In multiple-regression results, patient satisfaction with the doctor and with the hospital had different determinants.     

Quality and correlates of medical record documentation in the ambulatory care setting

Background  

Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record.     

Evaluation of the DINAMAP blood pressure monitor in an ambulatory primary care setting

Automatic blood pressure recorders have gained acceptance in many clinical settings. New devices have usually been validated with invasive monitoring as the "gold standard." There is a lack of sound empirical evidence, however, supporting the routine use of these monitors in ambulatory settings. This study evaluated the DINAMAP 8100, an oscillometric automated blood pressure monitor, using the Hawksley Random-Zero Sphygmomanometer as the standard. A sample of 80 normotensive and hypertensive ambulatory patients from the Department of Family Medicine at the Medical University of South Carolina were studied. A clinical trial was conducted in which readings from the DINAMAP 8100 were compared with those from the Hawksley Random-Zero Sphygmomanometer, in a 2 (instrument) X 2 (arm) X 2 (investigators) X 4 (pairs of simultaneous measurements) factorial design. The DINAMAP 8100 overestimated systolic readings (mean difference = 7.6 +/- 9.1 mmHg, P less than .0001, paired t test). More than one third of systolic measurements and one quarter of diastolic measurements were greater than 10 mmHg discrepant from the standard. The results of this study suggest that routine use of the DINAMAP 8100 would lead to serious misclassification errors in screening for hypertension and in the follow-up of known hypertensive patients. The DINAMAP 8100, therefore, is not an appropriate instrument for routine use in primary care settings.     

Safety risks in the ambulatory setting

Over the past decade, the focus of safety implementation has been on hospital settings, and most research on patient safety has examined hospital care. Yet, each year, 300 Americans are seen in ambulatory settings for every 1 person admitted to a hospital, and research shows that errors in ambulatory settings can be just as devastating as those in hospitals, and, as in the hospital setting, ambulatory errors or events often trigger legal action. The American Medical Association's report summarizing and compiling the past decade's research identifies 3 general gaps in the current research that impede safety analysis and 6 errors that are most common in ambulatory care that warrant attention. As new models of care emerge with an increased focus on continuity across care settings, there are also nascent opportunities for risk managers to analyze and evaluate ambulatory safety, implement strategies, and develop and test tools that could result in safer patient outcomes.     

Colon cancer screening in the ambulatory setting

BACKGROUND: Despite evidence of decreased mortality, recommendations for colon cancer screening have not been widely implemented by physicians. The objective of this study was to determine patient and clinician factors associated with screening for colon cancer. METHODS: A retrospective review of computerized medical records from primary care practices in an academic medical center was performed. Patients comprised men and women aged 50-74 with at least one visit between July 1, 1995 and June 30, 1997. Measurements included Fecal occult blood testing in the past 1 or 2 years, sigmoidoscopy in the previous 5 or 10 years, or colonoscopy in the past 10 years. RESULTS: A total of 6,039 patients were included in the analysis. Fecal occult blood testing had been performed in 44% of patients and sigmoidoscopy in 26%. Fifty-three percent of patients had undergone some type of colon cancer screening. In multivariate analysis, patient factors predictive of fecal occult blood testing included age (odds ratio (OR) per 5 years 1.05; 95% confidence interval 1.04, 1.06), Asian ethnicity (OR 1.23; 1.08, 1.41), number of visits during the study period (OR 1.05; 1.04, 1.06), recency of the last visit (OR 1.03; 1.02, 1.04), and having private insurance (OR 1.65; 1.04, 2.62). Predictors of sigmoidoscopy were similar except that patients with a family history of colon cancer and those with managed care insurance were also more likely to undergo sigmoidoscopy. Patients of nurse practitioners were less likely to receive fecal occult blood testing than were patients of physicians (OR 0.78; 0.65, 0.93). Patients of residents were less likely to undergo sigmoidoscopy than were patients of faculty (OR 0.79; 0.66, 0.94). CONCLUSIONS: Among patients seen in primary care practices, rates of colon cancer screening remain low, especially in patients who are younger, who have been seen less frequently, who are uninsured, or who do not have managed care insurance. Future research should explore these differences and should focus on increasing screening in all patient groups, especially in those who are underscreened.