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1
Mendis, S., Igbal Al Bashir, Lanka Dissanayake, Cherian Varghese, Ibtihal Fadhil, Esha Marhe, Boureima Sambo, et al. "Gaps in Capacity in Primary Care in Low-Resource Settings for Implementation of Essential Noncommunicable Disease Interventions." International Journal of Hypertension 2012 (2012): 1–7. http://dx.doi.org/10.1155/2012/584041.
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Objective.The objective was to evaluate the capacity of primary care (PC) facilities to implement basic interventions for prevention and management of major noncommunicable diseases (NCDs), including cardiovascular diseases and diabetes.Methods.A cross-sectional survey was done in eight low- and middle-income countries (Benin, Bhutan, Eritrea, Sri Lanka, Sudan, Suriname, Syria, and Vietnam) in 90 PC facilities randomly selected. The survey included questions on the availability of human resources, equipment, infrastructure, medicines, utilization of services, financing, medical information, and referral systems.Results and Conclusions.Major deficits were identified in health financing, access to basic technologies and medicines, medical information systems, and the health workforce. The study has provided the foundation for strengthening PC to address noncommunicable diseases. There are important implications of the findings of this study for all low- and middle-income countries as capacity of PC is fundamental for equitable prevention and control of NCDs.
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Kane, John M. "Utilization of Long-Acting Antipsychotic Medication in Patient Care." CNS Spectrums 11, S14 (December 2006): 1–8. http://dx.doi.org/10.1017/s1092852900025852.
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AbstractSchizophrenia is a complex disorder characterized by a broad spectrum of psychopathology. Aggressive efforts to bring the patient into remission should begin immediately after the first episode. Consequences of non-remission include poor prognosis, psychiatric and general medical complications, treatment resistance, and death from medical comorbidities and suicide. Prevention of relapse following remission is critical to the well-being and optimal functioning of patients with schizophrenia.The key to optimizing patients' outcomes is to ensure a patient's long-term continuation on medication. As treatment discontinuation can greatly impact the progression of the illness and the patient's ultimate outcome, selecting a treatment with maximum treatment effectiveness is optimal. Nonadherence to treatment is extremely prevalent among patients with schizophrenia, due to such factors as impaired cognition, lack of insight, and side effects associated with antipsychotic treatment.Atypical antipsychotics have shown some advantages over conventional antipsychotics in terms of reducing positive and negative symptoms of schizophrenia, preventing relapse, and incidence of tardive dyskinesia. Injectables and long-acting formulations of antipsychotics offer additional benefits in terms of ensuring treatment adherence.
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Gleason, Patrick P., Brent W. Gunderson, and Kristin R. Gericke. "Are Incentive-Based Formularies Inversely Associated with Drug Utilization in Managed Care?" Annals of Pharmacotherapy 39, no. 2 (February 2005): 339–45. http://dx.doi.org/10.1345/aph.1e380.
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OBJECTIVE: To review recent studies comprehensively assessing the impact of incentive-based multitier formularies on pharmaceutical costs and utilization. DATA SOURCES: PubMed (2001–December 2003) was searched using the key terms formularies, cost-sharing, and drug costs. STUDY SELECTION AND DATA EXTRACTION: Studies addressing the impact of implementing multitiered incentive-based formularies as a central component of an outpatient drug benefit were selected. DATA SYNTHESIS: One study using pharmacy claims from 25 employers with data from 402 786 members modeled the range of anticipated plan/employer savings associated with single- to 3-tier shifts and found that, going from a single- to 3-tier benefit results in decreased plan/employer pharmaceutical costs from $650 to $494 (24% decrease) per member per year and decreased pharmaceutical utilization from 12.3 to 9.4 (23.6% decrease) prescriptions per member per year. Another study demonstrated that adding an additional tier decreased pharmaceutical utilization, with a dramatic increase in member contribution offsetting the plan's expected increase in expenditures. This shift in pharmaceutical expenditures appeared to have no effect on overall medical utilization over a 3-year follow-up. Finally, a study converting members from a single- to 3-tier incentive-based formulary, associated with two- to fourfold copayment increases, resulted in a 10% discontinuation rate for angiotensin-converting enzyme inhibitors, statins, and proton-pump inhibitors among members who were primarily hourly employees. For salaried workers, the addition of a tier to their benefit appeared to have minimal impact on pharmaceutical utilization. CONCLUSIONS: Emerging data suggest a potential inverse relationship between pharmaceutical utilization and incentive-based formularies that increase member contribution to drug costs. Future research should focus on identifying price points and percentage increases at which members are likely to begin discontinuing necessary medications.
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Galo, Jason, Bianca Madrid, and Warren Kupin. "Lanthanum-Induced Radiopaque Intestinal Precipitates: A Potential Cause of Intestinal Foreign Bodies." Case Reports in Nephrology 2019 (September 2, 2019): 1–3. http://dx.doi.org/10.1155/2019/1298674.
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Lanthanum carbonate is a commonly prescribed oral phosphate binder for use in patients with acute or chronic kidney disease. The elemental form of lanthanum is a soft metal, which will appear radiopaque on a standard X-ray radiograph. This case report illustrates the potential for Lanthanum to masquerade as multiple radiopaque intestinal foreign bodies, leading to the extensive mobilization of medical resources and consultations including serial X-ray monitoring, multiple consultants including acute care and colorectal surgery. Given the few published reports describing this finding in the literature, it is essential to consider Lanthanum precipitates in the differential diagnosis of radiopaque intestinal foreign bodies in patients with chronic kidney disease to avoid unnecessary utilization of medical resources for this predominantly benign condition.
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Paulukonis, Susan, Lynne Neumayr, Thomas D. Coates, Elliott Vichinsky, and Lisa Feuchtbaum. "Emergency Room Utilization by California Sickle Cell Patients During Pediatric to Adult Care Transition." Blood 116, no. 21 (November 19, 2010): 254. http://dx.doi.org/10.1182/blood.v116.21.254.254.
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Abstract Abstract 254 Clinical experience and research with sickle cell patients and those with other genetic diseases suggests that the period of “transition,” in which patients move from pediatric care to adult-centered clinical care, is a period of high health services utilization. Young adult patients may not have learned to effectively manage disease symptoms and may not be connected to a “medical home” or have established a relationship with a primary care physician or adult hematologist. Further, these patients may not have insurance coverage previously provided by parents or by public pediatric insurance programs. As part of a collaborative agreement through the Centers for Disease Control and Prevention (CDC) and the National Heart, Lung & Blood Institute (NHLBI), California and five other states are conducting epidemiologic surveillance to determine the prevalence of hemoglobinopathies as well as health services utilization. Such data are essential to inform allocation of resources to meet the medical and social service needs of patients. Within the state, this project is a collaborative effort among the CA Dept. of Public Health Genetic Disease Screening Program, Children's Hospital Los Angeles and Children's Hospital & Research Center Oakland. Using administrative data obtained as a part of this effort, we describe emergency room (ER) utilization patterns among young adults with sickle cell disease. The CA Office of Statewide Health Planning and Development has collected data on ER utilization for the years 2005 – 2008. Using ICD 9 codes beginning with 282.6 to identify sickle cell-related ER visits during those years, we report usage patterns by patient age, gender, and payer type. To calculate risk of repeat ER visits, we used a negative binomial regression model (with 1 visit as the baseline for analysis, rather than 0 visits, due to the limitations of the data set). The following means and counts are adjusted to account for this shift. Analyses were conducted using SAS 9.1. The mean number of ER visits among sickle cell patients in the data set was 3.36 per year and 54% of visits were made by women, but gender differences in average visits per year per patient (3.18 female, 3.60 male) were not statistically significant. Medi-Cal (Medicaid) was the primary payer for 47% of visits during this time frame, and patients with Medi-Cal averaged nearly one additional visit per year (3.82 visits) compared to patients with other forms of payment (3.04 visits). Among patients seen at any time during the four years and controlling for gender and payer type, we found a 78% increase (IRR 1.78, 95% CI 1.59, 2.00) in risk of visiting the ER a second or subsequent time in a given year among the 20 to 30 year old group compared to all other age groups, a four fold increase (IRR 4.22, 95% CI 3.61, 4.93) in risk of a second or subsequent visit in a year compared to the group aged 10 to 20 years, and a 30% increase (IRR 1.34, 95% CI 1.16, 1.55) compared to the group 30 to 40 years of age. Average number of visits in the transition age group was 4.53 per year, compared to 1.93 per year in the 10 to 20y group and 3.56 in the 30 to 40y age group. The number of individuals visiting the ER per year was higher in this age group compared to the two adjoining age groups (520 individuals on average per year for 20 – 30y, vs. 311 per year for 10 – 20y and 355 for 30 to 40y). The increase in visits per year of age can be seen (Figure 1) to begin at age 18 or 19 and continue to approximately age 30. The proportion of patients with no insurance coverage increased from 8% in the 10 to 20y age category to 19% of patients in the 20 to 30y age category, and remains high for the subsequent age categories (11 to 17%). The transition period from pediatric care to adult care in California sickle cell patients is marked by a dramatic increase in emergency room visits (both more patients visiting and more visits per patient) compared to other age groups. ERs are also visited significantly more often by uninsured sickle cell patients in this age group than other age groups. Patients in this age group would likely benefit from access to a medical home model of care.Figure 1.Mean Annual Number of Visits by Age of Patient among Those Seen in ER with SCD-related ICD 9 Codes, California, 2005–2008Figure 1. Mean Annual Number of Visits by Age of Patient among Those Seen in ER with SCD-related ICD 9 Codes, California, 2005–2008 Disclosures: Coates: Novartis: Research Funding, Speakers Bureau.
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Bersabe, Adrian R., Michael Osswald, and Nathan M. Shumway. "Peripheral Blood Smear Utilization within a Military Hematology/Oncology Fellowship Program." Blood 124, no. 21 (December 6, 2014): 5980. http://dx.doi.org/10.1182/blood.v124.21.5980.5980.
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Abstract Background: The practice of peripheral blood smear (PBS) interpretation is considered an important diagnostic skill in Hematology/Oncology (HO). The Accreditation Council of Graduate Medical Education (ACGME) requires trainees to become proficient in the preparation and interpretation of blood smears. We explored practice patterns of PBS utilization in a tertiary care, military medical center HO fellowship program. Methods: A retrospective chart review was conducted on 350 consecutive outpatient referrals for benign hematology diagnoses (ICD-9 codes 280-289) in a military medical center, from August 2011 to March 2012. Data obtained from the electronic medical records (EMR) included patient demographics, pertinent medical history, labs ordered, and provider status (resident, fellow, or staff). We also recorded HO ordering patterns for complete blood counts (CBC) and PBS and documentation of PBS findings. For those encounters in which the findings were documented, we reported any further diagnostic studies ordered. The practices of PBS review by HO clinicians and hematopathologists (HP) were also compared. Results: 334 of 350 records reviewed met inclusion criteria for the study. Of the 16 records excluded, one was due to age > 85, 11 due to malignant oncology diagnoses, and 4 were unavailable within the EMR. The median age was 52.5 with males representing 52% of the cohort. 43.8% were self-reported as Caucasian, 23.6% African-American, and 32.6% “Other.” The distribution of diagnoses were 52.7% (n = 176) erythrocyte (RBC) disorders, 23.0% (n = 77) leukocyte (WBC) disorders, 10.2% (n = 34) platelet (PLT) disorders, and 14.1% (n = 47) falling into the category of “other.” The five most common diagnoses were anemia, unspecified (n = 74, 19.3%), iron deficiency anemia (n = 53, 13.8%), leukocytosis, unspecified (n = 37, 9.6%), thrombocytopenia, unspecified (n = 31, 8.1%), and leukopenia, unspecified (n = 16, 4.2%) corresponding to ICD-9 codes 285.9, 280.9, 288.6, 287.5, and 288.5, respectively. A CBC was ordered in 82.9% encounters (n = 277/334, 95% confidence interval [CI], 78.9%-87%) A PBS was ordered in 52.3% of cases in which a CBC was ordered (n = 145/277, 95% CI, p < 0.001). There was no statistical significance between the rates at which residents, fellows, or staff ordered PBS with percentages of 40% (n = 18/45), 43.6% (n = 89/204), and 44.7% (n = 38/85), respectively. A HP reviewed 5.7% (n=19/334) of the CBC’s obtained. If a PBS was ordered, findings were documented in the EMR for 49% of cases (71/145). In the 71 encounters that had PBS documentation, only 7 had HP review (9.9%). Examination of PBS led to further evaluation in 40.8% (29/71) of cases, which represented 8.7% (29/334) of the entire cohort. Of these 29, there was one consult to Gastroenterology, one imaging study ordered (ultrasound for splenomegaly), 9 bone marrow biopsies (12.7%), and lab work in all 29. Of the labs ordered, 8 (27.6%) were studies for hemolysis (DAT, LDH, haptoglobin), 10 (34.5%) were studies for myeloproliferative disease (Jak2, BCR-ABL), and 5 (17.2%) were peripheral flow cytometry. A PBS was more likely to be ordered for WBC disorders (71.9%, CI 95%: 61.9%-81.9%; p ≤ 0.001), followed by PLT (61.3%, CI 95%: 44.2%-78.4%; p = 0.076) and RBC disorders (38.7%, CI 95%: 30.9%-46.5%; p ≤ 0.001), respectively. Of the 29 cases in which PBS findings were documented and further studies ordered, 8 (27.6%) were RBC disorders, 10 (34.5%) were WBC disorders, 6 (20.7%) were PLT disorders, and 5 (17.2%) fell into the category of “other.” In the “other” category, 2 were other specified disease of blood and blood-forming organs (289.89), and the remaining 3 were splenomegaly (789.2) polyclonal hypergammaglobulinemia (273), and monoclonal paraproteinemia (273.1). Discussion: The practice of interpreting the PBS is considered an important diagnostic skill for HO providers. In a military HO training program, PBS were ordered in about half of new benign hematologic outpatient referrals. When PBS were ordered, findings were documented in 49% of cases. While diagnoses could be made without getting PBS in a majority of cases, close to 10% of all benign hematology referrals had documented PBS fidings that led to further diagnostic evaluation. Disclosures No relevant conflicts of interest to declare.
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Pai, Ashok, Dinesh Kotak, Nancy Facher, Kyle Reader, Kevin Kong, Natalya Greyz, Jahan Tavakoli, et al. "Development of a Virtual Benign Hematology Consultation Service: Results of a Pilot Project Involving 5 Medical Centers." Blood 132, Supplement 1 (November 29, 2018): 824. http://dx.doi.org/10.1182/blood-2018-99-110009.
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Abstract Background: Benign hematology consultations constitute a sizable proportion of community hematology/oncology practices. There is a need for physicians with adequate training, experience, interest and expertise in evaluating and treating patients with these disorders1,2. Some hematologic issues are complex and require in-person histories and examinations, while others can be handled with advice electronically after a thorough chart review3. To improve the quality of the care provided to these patients, a virtual benign hematology consultative service was created. This program was developed in the setting of a multi-specialty group with a commonly accessible EMR, servicing 15 medical service area centers, each with their own hematology/oncology department. A pilot project was designed to evaluate the feasibility of performing benign hematology consults virtually with the goal of improving quality of care while simultaneously enhancing the expertise of the physicians performing the consultations. Methods: The setting for this program is a multi-specialty group with a capitated reimbursement model. A pilot project was begun in October 2017 between 2 participating medical centers and was expanded to include a total of 5 medical centers by April 2018. All non-urgent benign hematology consultation requests were submitted electronically through an 'e-consult' portal. Evidence based work ups for common hematologic conditions were developed with consensus amongst all 15 hematology departments and provided on the e-consultation landing pages. All urgent questions and in-patient consults were called in directly to an on-call physician. Results: Data from October 2017 through April 2018 are reported. During this time, there were 2013 consults submitted electronically for review. Of this, 1107 came under the non-specific 'Ask the Specialist' code, and 906 under a specific diagnosis code. Regarding the consults with a designated diagnosis code, anemia 239 (26.3%), abnormal SPEP 208 (22.9%), anticoagulation 142 (15.6%), thrombocytopenia 103 (11.3%), leukocytosis 73 (8.1%), thrombocytosis 56 (6.2%), erythrocytosis 45 (5.0%), leukopenia 40 (4.4%) were the most common inquires. The requests that came under the 'Ask the specialist' code included questions regarding iron deficiency, easy bruising, macrocytosis without anemia, elevated ferritin levels and an elevated PT/PTT to name a few . Of the 1107 'Ask the specialist' consults, 941 (85.0%) were handled with advice given electronically while 116 (15%) were triaged to an in-person appointment. When evaluating the specific diagnosis codes, 575 (63.4%) were handled with advice given electronically. The most commonly triaged diagnosis for in-person appointments were thrombocytosis (60.7%), leukopenia (50.0%) and thrombocytopenia (47.6%). 90.3% of the consultation requests were addressed within 24 hours. When evaluating the number of consults on each day of the week, there were an average of 32.7, 25.8, 19.6, 24.4 and 18.2 consults triaged Monday through Friday respectively. The time necessary to complete an electronic consult was calculated based on data from 7 hematologists with a sample size of 197 consults. It took an average of 14.47 minutes to complete each consultation when performed electronically (95% CI, 14.02 mins - 14.91 mins). This is similar to the time reported by Cecchini et al. in their experience with this program at the VA health system3. All referring physicians were surveyed regarding their perceptions of the program, scaling their responses from 1 to 5. When asked if the work-up algorithms were helpful, if the recommendations received were clear and whether it was easy to access the specialist, the weighted average responses were 4.60, 4.50 and 4.0 respectively. Conclusions: This was a pilot program to assess the feasibility of a virtual hematology consultative service. The initial success of the program shows that it is possible to provide high value consultations to referring providers in an expeditious manner that enhances quality of care by having experts focused in the area perform the evaluation. Patients are also spared a visit to the hematology/oncology clinic to discuss a benign condition, and therefore has the added benefit of reduced anxiety4. Future studies will involve measuring outcomes of patients who were managed virtually, and the effect of the recommendations on the utilization of laboratory tests. Disclosures No relevant conflicts of interest to declare.
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Benca, R., R. Ferziger, E. M. Wickwire, S. Bertisch, J. Biddle, M. Boustani, L. Culpepper, et al. "1185 Developing A Care Pathway For Insomnia In Older Adults And Adults With Dementia: Results Of A Consensus Meeting." Sleep 43, Supplement_1 (April 2020): A452—A453. http://dx.doi.org/10.1093/sleep/zsaa056.1179.
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Abstract Introduction Insomnia among older adults and dementia patients carries a high public health burden. Yet, treatment is inconsistent or absent. Standardized, programmatic carepaths can be implemented in clinics/systems/communities to address this after tailoring to local environments. To determine what elements should be included, a consensus meeting was convened, which included discussion, voting on components, and further consensus-building among diverse stakeholders. Methods Participants represented a wide range of stakeholders and specialties, including academic research, clinical care, industry, government, payors, sleep medicine, primary care, geriatrics, psychiatry, neurology, nursing, pharmacy, quality, and implementation science. 27 statements regarding key components of carepaths for insomnia in elderly and dementia populations were presented and discussed. These represented items addressing identification of patients, screening and assessment, deciding treatment modality and delivery, providing behavioral treatment, providing pharmacotherapy, addressing combined therapy, addressing comorbidities, and incorporating outcome evaluation. All N=20 participants voted individually whether they agreed or disagreed with each statement. Items were scored as 0=strongly agree, 1=agree, 2=disagree, and 3=strongly disagree. Mean scores were evaluated and responses were dichotomized to agree/disagree. Results Despite diversity among attendees, median rate of agreement was 95% (IQR=85-95%). Mean score was 0.69 (SD=0.31). 95%CIs were computed for each proportion and compared to the mean. The following elements were significantly different from the mean (p<0.05): medication decision trees (M=0.25), accounting for comorbidities (M=0.26), include outcome evaluation (M=0.30), utilization of EMR (M=0.40), incorporate caregiver (M=0.42), and differ across parts of the system (M=1.79). Conclusion Insomnia carepaths for older adults should address identification, screening and assessment, treatment decisions, treatment type and delivery, and evaluation. Organizations should consider these elements when designing carepaths for insomnia among older adults and dementia patients. Consensus-building should begin during the process of prioritizing care path components. Support Merck Research Labs provided support
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Broers, Michelle, Jodi Wojcik, and Lindsey k. Journey. "579 Benefits of Licensed Clinical Social Worker Utilization in an Adult Burn Clinic: More Than Just Checking the Box." Journal of Burn Care & Research 42, Supplement_1 (April 1, 2021): S141. http://dx.doi.org/10.1093/jbcr/irab032.229.
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Abstract Introduction Our burn institution cares for critically ill burn patients and provides post-acute care for a large referral base. The clinic is staffed by a wound certified physical therapist, an advanced practice registered nurse and a licensed clinical social worker (LCSW), with consult access to Trauma/Burn Surgeons. The incidence of acute stress symptoms after burn injury is noted in up to 35% to 40% of patients. Therefore, it is important to identify symptoms of anxiety and depression early and begin symptom management. Burn patients have access to a multi-disciplinary team, and a licensed therapist, that can identify symptoms of acute stress and make recommendations for appropriate treatment in concert with the medical staff. This project seeks to determine the prevalence of acute stress in post-acute burn patients seen in an adult burn clinic and the benefits of utilizing a Licensed Clinical Social Worker to perform screening. Methods For a one-year period all burn patients in the burn clinic were screened by the LCSW. The subjects underwent initial screenings for depression, anxiety, and suicide risk at their first clinic visit. The PHQ-2 and PHQ-9 were utilized to assess depression, the GAD-7 for anxiety and the Columbia Suicide scale to assess suicide risk. Patients were initiated into multi-modal therapies based on specific scoring. These intervention strategies were based on the Depression Screening Protocol which included education on depression, and/or anxiety, with or without participation in a Trauma/Burn Peer Support Group. Patients were prescribed medication per provider discretion, and/or connected to community resources such as, counseling, and psychiatric mental health services. Results During the one-year assessment period screening compliance was >90%. During this period, >50% of patient’s scores were clinically significant for acute stress. Over half of those that screened positive were connected to community resources of counseling services or psychiatric care. 100% of those that screened positive were given education and connection to peer support services. An incidental correlation was noted between increased total body surface area involvement and work-related accidents with increased symptomology. Conclusions The inclusion of an LCSW in the burn clinic has improved the overall care of the burn injured patient. The assessment of depression and anxiety related to the burn injury has led to an increase in peer support participation and an increase in referrals to counseling and/or psychiatric services.
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Mogle, Bryan T., Robert W. Seabury, Zachary Jones, Christopher D. Miller, and Jeffrey M. Steele. "The Culture of Carbapenem Overconsumption: Where Does It Begin? Results of a Single-Center Survey." Hospital Pharmacy 54, no. 3 (May 8, 2018): 175–79. http://dx.doi.org/10.1177/0018578718775328.
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Purpose: The United States has seen an increased consumption of carbapenem antibiotics in recent years. The increased utilization of these agents has potential negative consequences, including the increasing incidence of carbapenem-resistant Enterobacteriaceae. Reasons for the rise in carbapenem use among providers in acute care hospitals are not well elucidated in literature. The objectives of this study were to identify factors that influence empiric carbapenem use among providers in a single academic medical center, and to assess therapeutic knowledge pertaining to carbapenem use. Methods: A cross-sectional, single-center, 9-item electronic research survey was developed independently and validated by an infectious diseases pharmacist and infectious diseases physician. The survey was distributed to email accounts of providers at a single academic medical center. Demographic data, factors affecting carbapenem prescription, and baseline therapeutic knowledge were assessed. Results: Ninety-five of 416 providers responded to the survey (response rate of 22.8%). Respondents were well distributed across all levels of training with primary roles in internal medicine and surgery. The most important factors influencing empiric carbapenem use were suspected pathogens at the site of infection, drug allergies, history of multidrug resistant organisms, severity of illness, type of infection, and local resistance rates. A recommendation from a pharmacist was selected as the most likely factor for deterring carbapenem use. Misconceptions pertaining to penicillin drug allergy and beta-lactam cross reactivity, knowledge of local resistance rates according to the institutional antibiogram, and comparative efficacy data for carbapenems were apparent across all levels of training. Conclusions: Provider misconceptions regarding several factors appear to contribute to unnecessary use of carbapenems. An opportunity exists for hospital pharmacists to improve the prescribing patterns of carbapenems by correcting provider misconceptions through education.
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Damien, Hansra, Ramdial Jeremy, Martinez Gianni, Farooq Faheem, Alfredo Torres, Saravia Diana, Ashwin Mehta, and Eugene Ahn. "Disparities Between Patient and Hematology/Oncology Physician Expectations for Integrative Oncology in an Ethnically Diverse Population." Blood 124, no. 21 (December 6, 2014): 2641. http://dx.doi.org/10.1182/blood.v124.21.2641.2641.
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Abstract Purpose: Evidence shows increased patient utilization of various integrative care modalities. In part, patients desire greater self-empowerment to potentially manage their symptoms, improve quality of life and overall outcomes. Measurements of patient and physicians opinions regarding the importance of integrative care are lacking. We aim to compare expectations of what “comprehensive care” means between hematology/oncology physicians and patients. Methods: Approval from the University of Miami IRB was obtained prior to initiation of data collection. Adult patients (pts) and hematology/oncology physicians (MDs) at an academic tertiary care medical center in Miami, Florida were enrolled to complete a survey. Demographics collected include: age, gender, race, & ethnicity. Clinical information collected include cancer subtype and treating hematologist/oncologist. The survey consisted of 7 questions assessing personal opinions on “comprehensive care”. The questions specifically asked “In addition to standard care, it is important to incorporate/provide” nutrition services, exercise therapy, spiritual/religious counseling, supplement/herbal advice, support groups, music therapy, or other complimentary medicine services (acupuncture, massage, relaxation therapy). Answers were recorded on a 5 point Likert scale (1=highly disagree, 2= disagree, 3=neutral, 4=agree, 5= highly agree) then converted into 2 categories (1,2,3= neutral/disagree vs. 4,5=agree). Fisher’s exact test with 2 sided p-value used to compare significance between MDs & pts responses. Results: 670 pts and 55 MDs enrolled from June 2013 to May 2014. Pts demographics included a mean age 55 with range 18-88 with 44% male and 56% female. 57% of patients were Hispanic vs. 43% not Hispanic. 81% were white, 11% black/African American, 2% Asian/Pacific Islander, and 6% other. 17% of patients had hematologic disorders (85% malignant 15% benign) vs. 83% of patients had solid oncologic malignancies. MD demographic data will be reported in poster. Survey results: 83% of pts agree that nutritional advice is important vs. 67% of MDs, p=0.01. Significant disparities were also seen for exercise therapy (86% vs. 73% respectively, p=0.02), spiritual/religious counseling (69% vs. 50% respectively, p=0.01), supplement/herbal therapies (86% vs. 56% respectively, p=0.0001), music therapy (66% vs. 30% respectively, p=0.0001), and “other complementary services” such as acupuncture, massage and relaxation therapy (70% vs. 45% respectively, p=0.004). The lone service that did not demonstrate significant disparity of opinion was support groups (72% vs. 68% respectively, p=0.5). Conclusion: A significant majority of adult hem/onc patients seen at a major academic institution in South Florida feel that it is important to incorporate nutrition advice, exercise therapy, spiritual/religious counseling, supplement/herbal advice, support groups, music therapy, and other complimentary services such as acupuncture, massage and relaxation therapy as part of their “comprehensive care”. With the exception of support groups, MDs tend to value integrative oncology services significantly less than patients do. It is expected that increased availability and utilization of integrative oncology modalities at tertiary hospital sites could improve patient satisfaction and quality of life, and enhance patients’ therapeutic alliance with their medical team and plan as patient and physician definitions of “comprehensive care” more closely merge. This is the first study published to our knowledge that examined disparities between patient and physician expectations for comprehensive care in an ethnically diverse, predominantly Hispanic population. Disclosures No relevant conflicts of interest to declare.
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Kirk, Susan E., Amanda Bell Grimes, Sayali Shelke, Jenny M. Despotovic, and Jacquelyn M. Powers. "The Cost of a "Benign" Condition: Healthcare Utilization and Infectious Outcomes in Young Children with Autoimmune Neutropenia." Blood 132, Supplement 1 (November 29, 2018): 2220. http://dx.doi.org/10.1182/blood-2018-99-110109.
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Abstract Background: Autoimmune neutropenia (AIN) is the most common chronic neutropenia of childhood. Despite the expectation of a benign clinical course, many such patients undergo extensive evaluation to rule out congenital neutropenia or malignant disease, are followed within a subspecialty hematology clinic until resolution, and are given strict infectious precautions including emergency center (EC) assessment during febrile episodes. Data on healthcare utilization and rate of serious infections in young patients with AIN is limited. Objective: To evaluate the utilization of routine subspecialty and emergency healthcare and incidence of serious bacterial infections in young children with AIN at a large tertiary care children's hospital. Methods: All patients with a diagnosis code of leukopenia, neutropenia, or AIN followed within the outpatient hematology clinic of a large tertiary hospital from 2014 to 2016 were identified. Manual review of the electronic medical record was performed to assess patient eligibility and perform data collection. Patients age ≤5 years, with absolute neutrophil count (ANC) ≤500/µL persisting for ≥3 months, and a clinical diagnosis of AIN as determined by a hematology provider were included. Patients were excluded if they were lost to follow up prior to neutropenia resolution, had AIN secondary to underlying systemic autoimmune or immunologic disorder, neutropenia persisting beyond age 5 years, or if the etiology of neutropenia was unclear. Data on clinical assessment, laboratory parameters, immune and infectious evaluations, and total number of outpatient and EC assessments for fever were collected. Results of anti-neutrophil antibody testing were reviewed but no patients were included or excluded based on those results. EC visits for evaluation of fever in 3 representative patients were reviewed for charge capture data. All charges during the reviewed time period remained constant. Results: From 2014 to 2016, 46 patients (20 male [44%], median age at diagnosis 12 months) diagnosed with AIN met eligibility criteria and were followed in the outpatient hematology clinic for a total of 450 outpatient visits (Table 1). Median duration from initial identification of neutropenia to discharge from hematology clinic was 19 months (range 6 to 85 months). Thirteen patients (28%) had bone marrow evaluation to rule out infiltrative disease or marrow failure etiologies. Nine patients (20%) had genetic testing, the majority of which (n=6) were targeted sequencing for congenital neutropenia. Thirty-six patients (78%) had one or more EC encounters for evaluation of fever, and the cohort had a combined 125 such encounters. Of 155 blood cultures drawn, 3 returned positive. Positive cultures resulted in repeat blood cultures being drawn and hospital admission for antibiotics and clinical monitoring. However, all were determined to be contaminants that did not require treatment. Total charges associated with EC visits for the cohort are estimated at $471,375 based on a cost of $3771 per visit (Table 2). Those patients with ANC <500/µL at the time of presentation with isolated fever were admitted for observation per hospital policy, resulting in 29 inpatient hospitalizations after initial hematology visit. Conclusion: Over a 3-year period, no serious bloodstream or life-threatening infections were identified in a cohort of 46 young children with AIN presenting to the EC for assessment of fever at a single, large tertiary care children's hospital. A conservative estimate of EC charges for this cohort totaled just under half a million dollars for all visits in the study period. Costs would be expected to vary by center, and additional intangible costs include parental and patient anxiety, travel costs, and missed school or work. Further prospective research is needed to determine the potential for shifting toward a less intensive, more cost-effective management paradigm among young children with AIN without compromising patient safety. Disclosures Despotovic: Novartis: Research Funding; AmGen: Research Funding; Sanofi: Consultancy.
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Bollmann, Andreas, Sven Hohenstein, Vincent Pellissier, Katharina Stengler, Peter Reichardt, Jörg-Peter Ritz, Holger Thiele, et al. "Utilization of in- and outpatient hospital care in Germany during the Covid-19 pandemic insights from the German-wide Helios hospital network." PLOS ONE 16, no. 3 (March 25, 2021): e0249251. http://dx.doi.org/10.1371/journal.pone.0249251.
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Background During the early phase of the Covid-19 pandemic, reductions of hospital admissions with a focus on emergencies have been observed for several medical and surgical conditions, while trend data during later stages of the pandemic are scarce. Consequently, this study aims to provide up-to-date hospitalization trends for several conditions including cardiovascular, psychiatry, oncology and surgery cases in both the in- and outpatient setting. Methods and findings Using claims data of 86 Helios hospitals in Germany, consecutive cases with an in- or outpatient hospital admission between March 13, 2020 (the begin of the “protection” stage of the German pandemic plan) and December 10, 2020 (end of study period) were analyzed and compared to a corresponding period covering the same weeks in 2019. Cause-specific hospitalizations were defined based on the primary discharge diagnosis according to International Statistical Classification of Diseases and Related Health Problems (ICD-10) or German procedure classification codes for cardiovascular, oncology, psychiatry and surgery cases. Cumulative hospitalization deficit was computed as the difference between the expected and observed cumulative admission number for every week in the study period, expressed as a percentage of the cumulative expected number. The expected admission number was defined as the weekly average during the control period. A total of 1,493,915 hospital admissions (723,364 during the study and 770,551 during the control period) were included. At the end of the study period, total cumulative hospitalization deficit was -10% [95% confidence interval -10; -10] for cardiovascular and -9% [-10; -9] for surgical cases, higher than -4% [-4; -3] in psychiatry and 4% [4; 4] in oncology cases. The utilization of inpatient care and subsequent hospitalization deficit was similar in trend with some variation in magnitude between cardiovascular (-12% [-13; -12]), psychiatry (-18% [-19; -17]), oncology (-7% [-8; -7]) and surgery cases (-11% [-11; -11]). Similarly, cardiovascular and surgical outpatient cases had a deficit of -5% [-6; -5] and -3% [-4; -3], respectively. This was in contrast to psychiatry (2% [1; 2]) and oncology cases (21% [20; 21]) that had a surplus in the outpatient sector. While in-hospital mortality, was higher during the Covid-19 pandemic in cardiovascular (3.9 vs. 3.5%, OR 1.10 [95% CI 1.06–1.15], P<0.01) and in oncology cases (4.5 vs. 4.3%, OR 1.06 [95% CI 1.01–1.11], P<0.01), it was similar in surgical (0.9 vs. 0.8%, OR 1.06 [95% CI 1.00–1.13], P = 0.07) and in psychiatry cases (0.4 vs. 0.5%, OR 1.01 [95% CI 0.78–1.31], P<0.95). Conclusions There have been varying changes in care pathways and in-hospital mortality in different disciplines during the Covid-19 pandemic in Germany. Despite all the inherent and well-known limitations of claims data use, this data may be used for health care surveillance as the pandemic continues worldwide. While this study provides an up-to-date analysis of utilization of hospital care in the largest German hospital network, short- and long-term consequences are unknown and deserve further studies.
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Kono, Scott Arthur, Jammie Reichel, Alex R. Menter, Stephen Armond Mayer, Lillian Klancar, Keren Sturtz, Vignesh Narayanan, et al. "Implementing and analyzing a distress screening tool (DST) in a community oncology setting: Breaking down barriers to comprehensive medical and psychosocial (PS) care—The Kaiser Permanente Lone Tree, CO (KP-LT) experience." Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017): e21553-e21553. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.e21553.
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e21553 Background: PS distress (D) in cancer patients is an underestimated barrier to optimal care. The NCCN recommends D screening and intervention for D scores (DS) ≥4. KP is an ideal environment for large-scale screening. We sought to identify barriers in DST compliance, find a successful standardized workflow (SWF), and understand sources of D to elevate the standard of PS care. Methods: The DST was administered by the physician at completion of initial encounter to all new patients. Compliance recorded before and after implementing a SWF in 2/2016. Our DST utilizes 4 Major Categories of Distress (MCD) [Practical (P), Social (S), Health (H), Emotional (E)] to identify specific areas of D, and stratify DS by diagnosis [Benign (BH)-, Malignant- (MH) Hematology, Solid Tumor (ST)]. Clinic outreached any patient with a 4+ DS. DST was modified (mDST) 9/2016 to provide a DS for each MCD rather than 1 overall DS to improve practicality. Results: 936 DSTs completed from 6/2015-1/2017 (304/632 were mDST). DST compliance increased from 51% to 78% after the SWF. 289/632 (46%) scored 4+ (avg. DS 6.15). 153/304 (54%) mDSTs scored 4+ in ³ 1category. The avg. DS was 3.9 (n=936). Avg. DS for: BH= 3.67 (50% scored 4+, avg. 6.0), MH=3.79 (49% score 4+, avg. 6.14), and ST=4.02 (54% score 4+, avg. 6.18). The 3 most common concerns in each MCD are reported in Table 1. Most frequent outreach requests: Dietitian (n=88, 9%), LCSW (n=70, 7%), and Financial Counselor (n=50, 5%). Conclusions: Sources of D are a patient reported metric, not provider-assumed. DST use is feasible and essential to comprehensive cancer care. A SWF is crucial for success and led to a 27% increase in compliance. 4+ DS is frequent and was higher than expected in BH. Identifying specific stressors allows early intervention and improved resource utilization. [Table: see text]
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Faruque, A. S. G., and Abu Eusof. "Medical Care Utilization." Tropical Doctor 16, no. 2 (April 1986): 87–89. http://dx.doi.org/10.1177/004947558601600217.
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This paper describes the use-pattern of medical care prior to death caused by cholera outbreaks in rural Bangladesh. In nine rural communities 92 acute diarrhoeal deaths were recorded. These mainly occurred within 24 hours or less of diarrhoea onset, and were time-clustered. An on-the-spot stool culture survey of active cases confirmed cholera cases. In 50% of deaths, diarrhoea onset occurred between midnight and 9 am. Fifty-one percent of the fatalities had been treated earlier by village practitioners, another 20% had been attended by qualified doctors, and 8% had had no medical care. Oral rehydration therapy alone had been used in 29 cases, but 26 died within 24 hours. Of 43 persons who received intravenous therapy, oral rehydration and antibiotics, 21 (45%) died within 24 hours and 12 (28%) after 48 hours. Seventeen deceased had received no rehydration therapy. Early and adequate fluid therapy is required for optimal rehydration. Training of community people and health personnel, along with resources mobilization, will save lives by preventing unnecessary dehydration deaths.
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Sivarajah, Rebecca, Janelle Welkie, Julie Mack, Rachel S. Casas, Melody Paulishak, and Alison L. Chetlen. "A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment." Journal of Breast Imaging 2, no. 2 (January 8, 2020): 101–11. http://dx.doi.org/10.1093/jbi/wbz082.
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Abstract Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.
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Roper, Kathy O., Arya Sedehi, and Baabak Ashuri. "A cost-benefit case for RFID implementation in hospitals: adapting to industry reform." Facilities 33, no. 5/6 (April 7, 2015): 367–88. http://dx.doi.org/10.1108/f-05-2013-0041.
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Purpose – The purpose of this paper is to analyze a conceptual framework to identify significant benefit and cost attributes of a radio-frequency identification (RFID) system for asset tracking in healthcare facilities. Sources of value function for RFID in healthcare are categorized according to major improvement. Several cost functions are proposed to measure aspects of automated tracking implementation. Design/methodology/approach – The four phases of problem definition, literature identification, assessment and analysis were used to begin the research. A cost–benefit analysis (CBA) was completed to identify the factors within healthcare with major benefits, and finally, a recommended group of items were identified to track with the CBA. Findings – RFID to manage mobile devices increases the utilization rate, decreases annual spending, allows withdrawal of funds for underutilized assets and establishes confidence that equipment is readily available when needed. These benefits provide improved staff productivity, quicker patient turnover, higher quality of care and more cost savings. Real-time location system technologies allow hospitals to be prepared for emergencies requiring the immediate use of medical devices without delay and allow staff to determine the status, condition and location of essential equipment, leading to a decrease in patient wait time. Additional improvements were also found. Originality/value – The transition from pay-for-service to pay-for-performance is taking place in an industry hampered by rising costs and limited available resources. Healthcare expenditures are estimated to grow dramatically, and various factors contribute to rising expenses, including an aging population and increased chronic conditions resulting in higher demand for care, poor quality and operational inefficiencies. Therefore, understanding benefits of new technology use like RFID is critical for improvement and efficiency in healthcare.
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Greenberg, Charles S., Caroline Dupre Vaughn, Alice Boylan, Jerry E. Squires, Sharon DeGrace, John Lazarchick, Adrian Reuben, Alan C. Finley, and Joseph Mazur. "Analyzing the Impact of Implementing a Systems-Based Hematologist into the Healthcare Delivery System at an Academic Medical Center." Blood 126, no. 23 (December 3, 2015): 4467. http://dx.doi.org/10.1182/blood.v126.23.4467.4467.
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Abstract There remains a clinical shortage of benign hematologists to manage the growing number of patients with non-malignant yet life-threatening and chronic blood diseases. The American Society of Hematology proposed creating System-Based Hematologist (SBH) positions to meet this need. The purpose of this study was to provide quantitative data regarding the impact that a SBH has on health care delivery in both the inpatient and outpatient settings. In 2011, the Department of Medicine successfully negotiated a Medical Directorship position for a SBH for the MUSC Health System. The position functions within the hospital as a part of the Medical Acute Critical Care Service Line, and the clinical service run by the SBH conducts inpatient consults daily. A benign hematology outpatient clinic was also established and is located on the hospital campus. In the years 2013-2014, clinic referrals of new patients grew 20% and the inpatient consult service grew by 38%. The SBH managed all hemophilia admissions from the emergency room and the use of recombinant blood products was reduced by an average of 35% per patient. The SBH evaluated the performance characteristics of the ROTEM instrument, recommended the instrument be purchased by the hospital for clinical use and collaborated to establish algorithms to guide replacement therapy. In CT Surgery, an anesthesiologist was trained in ROTEM and blood management who then served as the champion that implemented the ROTEM-based system for intra- and post- operative CABG care. From 2013 to 2014, we found that the use of FFP in CABG patients decreased from 25.8% to 12.7%. Platelet usage per patient dropped from 0.72 to 0.43. Cryoprecipitate decreased from 0.37 to 0.2 per patient. A ROTEM -based algorithm was also implemented to manage pre-procedure replacement therapy in patients with a coagulopathy from chronic liver disease. This protocol has led to reduction in fresh frozen plasma use from 3 units per patient to 0.4 units per patient, and has eliminated the use of pre-procedure INR correction as a target for promoting hemostasis. The ROTEM-guided algorithm resulted in safe and satisfactory outcomes for all liver disease patients requiring interventional procedures, as well as substantial cost savings. In addition, the SBH established a heparin-induced thrombocytopenia monitoring program. The EMR was specifically modified to provide guidance regarding calculating the 4T score and decision support for heparin-platelet factor 4 antibody testing and use of heparin alternatives. The SBH consults on patients that have positive heparin-platelet factor 4 assays and helps guide safe anticoagulation therapies in those patients that require treatment. Following the implementation of this program, serotonin release assays were reduced by 70% and there was also a substantial reduction in the use of direct thrombin inhibitors of 78%. Clinical outcomes in all patients today have been satisfactory with no major thrombotic complications apart from one patient that could not receive anticoagulation due to recent surgery, who fully recovered despite having DVT/PE. One patient that had a negative heparin platelet factor 4 assay became positive upon repeat testing and suffered arterial thrombosis that has resolved without any residual deficit. The SBH also educates medical students, interns, residents and fellows in the inpatient and outpatient settings. The addition of a nurse practitioner was necessary as the program has developed a rapid access anemia clinic to diagnose and treat pre-and post-op anemia. The MUSC SBH position is transitioning to play a role in a patient blood management program that will serve the entire healthcare network. In conclusion, this study documents a SBH can reduce cost of HITT management, blood product utilization in CABG and pre-procedure management of the coagulopathy in chronic liver disease as well as hemophilia management. The clinical services provided by the SBH in the clinics and outpatient setting can further enhance the education of students, residents and fellows in academic medical centers. The SBH must have the administrative support to initiate and implement programs through productive collaboration with colleagues within the health care system.The ASH program to encourage implementation of SBH positions and training should provide rewarding career opportunities for hematologists interested in non-malignant hematologic disorders. Disclosures No relevant conflicts of interest to declare.
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Lim, Ming Yeong, Caroline Dupre Vaughn, Lauren T. Shane, and Charles S. Greenberg. "Strategies to Improve Safety and Outcomes Utilizing Systems-Based Hematologists in IVC Filter Placement and Management in an Academic Medical Center." Blood 128, no. 22 (December 2, 2016): 4739. http://dx.doi.org/10.1182/blood.v128.22.4739.4739.
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Abstract In large academic institutions, there are multiple disciplines and clinical scenarios that may require placement of inferior vena cava filters (IVCF). Both the Society of Interventional Radiology (SIR) and the American College of Chest Physicians (ACCP) have released guidelines for IVCF use, with the ACCP guidelines being more stringent due to the lack of survival benefit supported by level I data. Several publications have reported high rates of retrievable IVCF complications. In response to these risks and low retrieval rates, the U.S. FDA issued an updated safety alert in 2014 recommending that implanting physicians and clinicians responsible for the ongoing care of patients with retrievable IVCF consider removing the filter as soon as protection from pulmonary embolism is no longer needed. A systems-based hematologist (SBH) plays a vital role in navigating the health care system in the use of therapeutic and device agents that crosses multiple disciplines by implementing evidence-based strategies to improve safety and outcomes. Previously, we used our institution's electronic health record (EHR) system to assist in improving the quality of care and reducing the cost of heparin-induced thrombocytopenia management, blood product utilization in cardiac surgery and pre-procedure management of coagulopathy in chronic liver disease (Greenberg et al. Blood. Vol. 126, No. 23; Abstract 4467). As a first step, the purpose of this study was to report our healthcare system use of IVCF to: a) define the scope of practice and b) to identify areas for improvement. We propose a practical plan that will assist in improving clinician performance, patient education, and acute and chronic management of IVCF in a large healthcare network based on our recent success utilizing EHR to manage complex medical care. A retrospective review of all IVCF placement performed between July 2014 and December 2015 was conducted. A total of 181 IVCF were placed; 26 (14.4%) permanent IVCF, 143 (79.0%) retrievable IVCF, 12 (6.6%) unknown. Mean age at IVCF placement was 59.34 years (range: 19 - 85); 46.4% were male. Ninety-six (53.0%) patients had active cancer. Surgical Services and Medical Services requested IVCF placements in 112 (61.9%) patients and 69 (38.1%) patients, respectively. Only 13 (7.2%) patients had a SBH consultation prior to IVCF placement. Per SIR guidelines, 60.2% (n=109) of IVCF were placed for absolute indications, 15.5% (n=28) for relative indications, 14.4% (n=26) prophylactically and 9.9% (n=18) with no clear indications. Of the 143 retrievable IVCF, 21 patients died during their hospitalization or were discharged to hospice. Of the remaining 122 cases, documentation of the presence of an IVCF was present in 107 (87.7%) discharge summaries, and outlined instructions for filter retrieval were seen in 19 (15.6%) cases. Only 29 (23.8%) IVCF were retrieved at a mean interval of 159 days (range: 4-511 days). Of the 21 patients that had IVCF placed prophylactically, only 7 (33.3%) IVCF were retrieved. While many of the retrievable filters were placed because of an absolute contraindication (n=64) or relative indication for high-risk of complication to anticoagulation (n=13), 37 (48.1%) patients were discharged on a regimen of anticoagulant therapy. We performed a root cause analysis and identified that a lack of awareness of IVCF evidence-based indications could have played a role in filter use patterns and the lack of a structured system for IVCF tracking in some clinical services resulted in poor IVCF retrieval rates. We propose a practical plan requiring clinicians requesting for IVCF to check an evidence-based indication via EHR. When an IVCF is placed, the Anticoagulation and Bleeding Management Specialty Nurse maintains a log of these patients and provides them with an Information Sheet that lists the date, indication and type of IVCF, specific instructions on IVCF retrieval, and a follow-up appointment in the Benign Hematology clinic for anticoagulant management. The Information Sheet is uploaded onto EHR for documentation. In conclusion, we identified the scope of practice and areas that could be improved by the adoption of a centralized and coordinated approach to monitor patients with IVCF. This study demonstrates the potential impact that a SBH has on health care delivery in both the inpatient and outpatient settings. Disclosures No relevant conflicts of interest to declare.
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Fiscella, Kevin, Peter Franks, and Carolyn M. Clancy. "Skepticism Toward Medical Care and Health Care Utilization." Medical Care 36, no. 2 (February 1998): 180–89. http://dx.doi.org/10.1097/00005650-199802000-00007.
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Crozier, David A. "Health Status And Medical Care Utilization." Health Affairs 4, no. 1 (January 1985): 114–28. http://dx.doi.org/10.1377/hlthaff.4.1.114.
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Andersen, Ronald, Meei-shia Chen, Lu Ann Aday, and Llewellyn Cornelius. "Health Status and Medical Care Utilization." Health Affairs 6, no. 1 (January 1987): 136–56. http://dx.doi.org/10.1377/hlthaff.6.1.136.
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Hendershot, Gerry E. "Health Status and Medical Care Utilization." Health Affairs 7, no. 1 (January 1988): 114–21. http://dx.doi.org/10.1377/hlthaff.7.1.114.
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Guendelman, Sylvia, and Joan Schwalbe. "Medical Care Utilization by Hispanic Children." Medical Care 24, no. 10 (October 1986): 925–40. http://dx.doi.org/10.1097/00005650-198610000-00006.
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Baram, Shira, Samantha A. Myers, Samantha Yee, and Clifford L. Librach. "Fertility preservation for transgender adolescents and young adults: a systematic review." Human Reproduction Update 25, no. 6 (October 21, 2019): 694–716. http://dx.doi.org/10.1093/humupd/dmz026.
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Abstract BACKGROUND Many transgender individuals choose to undergo gender-affirming hormone treatment (GAHT) and/or sex reassignment surgery (SRS) to alleviate the distress that is associated with gender dysphoria. Although these treatment options often succeed in alleviating such symptoms, they can also negatively impact future reproductive potential. OBJECTIVE AND RATIONALE The purpose of this systematic review was to synthesize the available psychosocial and medical literature on fertility preservation (FP) for transgender adolescents and young adults (TAYAs), to identify gaps in the current research and provide suggestions for future research directions. SEARCH METHODS A systematic review of English peer-reviewed papers published from 2001 onwards, using the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P) guidelines, was conducted. Four journal databases (Ovid MEDLINE, PubMed Medline, Ovid Embase and Ovid PsychINFO) were used to identify all relevant studies exploring psychosocial or medical aspects of FP in TAYAs. The search strategy used a combination of subject headings and generic terms related to the study topic and population. Bibliographies of the selected articles were also hand searched and cross-checked to ensure comprehensive coverage. All selected papers were independently reviewed by the co-authors. Characteristics of the studies, objectives and key findings were extracted, and a systematic review was conducted. OUTCOMES Included in the study were 19 psychosocial-based research papers and 21 medical-based research papers that explore fertility-related aspects specific for this population. Key psychosocial themes included the desire to have children for TAYAs; FP discussions, counselling and referrals provided by healthcare providers (HCPs); FP utilization; the attitudes, knowledge and beliefs of TAYAs, HCPs and the parents/guardians of TAYAs; and barriers to accessing FP. Key medical themes included fertility-related effects of GAHT, FP options and outcomes. From a synthesis of the literature, we conclude that there are many barriers preventing TAYAs from pursuing FP, including a lack of awareness of FP options, high costs, invasiveness of the available procedures and the potential psychological impact of the FP process. The available medical data on the reproductive effects of GAHT are diverse, and while detrimental effects are anticipated, the extent to which these effects are reversible is unknown. WIDER IMPLICATIONS FP counselling should begin as early as possible as a standard of care before GAHT to allow time for informed decisions. The current lack of high-quality medical data specific to FP counselling practice for this population means there is a reliance on expert opinion and extrapolation from studies in the cisgender population. Future research should include large-scale cohort studies (preferably multi-centered), longitudinal studies of TAYAs across the FP process, qualitative studies of the parents/guardians of TAYAs and studies evaluating the effectiveness of different strategies to improve the attitudes, knowledge and beliefs of HCPs.
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JACOBI, F., H. U. WITTCHEN, C. HÖLTING, M. HÖFLER, H. PFISTER, N. MÜLLER, and R. LIEB. "Prevalence, co-morbidity and correlates of mental disorders in the general population: results from the German Health Interview and Examination Survey (GHS)." Psychological Medicine 34, no. 4 (April 21, 2004): 597–611. http://dx.doi.org/10.1017/s0033291703001399.
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Background. The German National Health Interview and Examination Survey (GHS) is the first government mandated nationwide study to investigate jointly the prevalence of somatic and mental disorders within one study in the general adult population in Germany. This paper reports results from its Mental Health Supplement (GHS-MHS) on 4-week 12-month, and selected lifetime prevalence of a broad range of DSM-IV mental disorders, their co-morbidity and correlates in the community.Methods. The sample of the GHS-MHS (n=4181; multistage stratified random sample drawn from population registries; conditional response rate: 87·6%) can be regarded as representative for the German population aged 18–65. Diagnoses are based on fully structured computer assisted clinical interviews (M-CIDI), conducted by clinically trained interviewers.Results. 12-month prevalence for any DSM-IV study disorder is 31% (lifetime: 43%; 4-week: 20%) with anxiety disorders, mood disorders and somatoform syndromes being the most frequent diagnoses. Retrospective age of onset information reveals that most disorders begin early in life. Co-morbidity rates among mental disorders range from 44% to 94%. Correlates of increased rates of mental disorders and co-morbidity were: female gender (except for substance disorders), not being married, low social class, and poor somatic health status. Health care utilization for mental disorders depended on co-morbidity (30% in ‘pure’, 76% in highly co-morbid cases) and varied from 33% for substance use disorders to 75% for panic disorder.Conclusions. Results confirm and extend results from other national studies using the same assessment instruments with regard to prevalence, co-morbidity and sociodemographic correlates, covering a broader range of DSM-IV disorders [i.e. somatoform disorders, all anxiety disorders (except PTSD), mental disorders due to substance or general medical factor, eating disorders]. Intervention rates were higher than in previous studies, yet still low overall.
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Parker, Jacob, Katharine Farrow, Rosalie Brooks, Danielle Leonard, Fernanda Cortez, and Courtney D. Thornburg. "Electronic Health Record Tools to Promote Transition Readiness and Knowledge for Adolescents and Young Adults with Hemophilia." Blood 134, Supplement_1 (November 13, 2019): 4685. http://dx.doi.org/10.1182/blood-2019-124561.
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Introduction: Challenges to the transition of care for adolescents and young adults with bleeding disorders negatively impact clinical outcomes. Transition of care is a Healthy People 2020 measure, and many Hemophilia Treatment Centers (HTCs) in the United States are developing a systematic approach based on the Got TransitionTM framework, which includes six core elements designed to aid patients and their families during this vulnerable period. To improve the quality of care delivered to transition-aged individuals with hemophilia, we developed a quality improvement initiative (QI) to track and monitor transition, to assess transition readiness, and to provide education based on patient-centered goals. Our global aim is to improve transition readiness and rate of successful transfer to an adult hemophilia provider by age 18-21y. We report results for the specific aim to increase the percentage of transition-aged individuals who complete transition readiness assessments and receive patient-centered goals education at annual comprehensive clinic appointments over a six-month cycle from 0 to 80%. Methods: We developed metrics and reports in Epic (electronic health record system) to track patients with hemophilia aged 12y and older who are eligible to begin the transition process. We also developed a Transition Readiness Assessment and a 15-question hemophilia-specific Skills Practicum to be completed by the patient in EPIC during their appointment. Based on responses to the Transition Readiness Assessment, patients select 2-3 goals for the year. Each selected goal generates a corresponding education handout. The tools are completed by patients with hemophilia between the ages of 12-21y at the time of rooming by the medical assistant for the annual comprehensive clinic appointment. Patients are excluded if they have significant developmental delays. During the appointment, the child life specialist for the HTC reviews the results of the Skills Practicum with the patient, and the HTC nurse reviews the Transition Readiness Assessment and the education handouts with the patient. Descriptive statistics were used to analyze the population and the results. Results: During the QI cycle, 20 of 43 transition-aged patients attended a comprehensive clinic visit and 17/20 (85%) completed all age-appropriate assessments. Patient characteristics and transition readiness results are shown in Table 1. The most frequently selected patient goals were "know my doctors' and nurses' names and roles" (29%), "know my doctor's phone number and call my doctor's office to make or change an appointment" (65%), and "have access to MyChart account and check MyChart" (47%). Four questions on the Skills Practicum test how to read a prescription. Five patients (29%) correctly answered all four questions. Conclusions: In summary, the Epic transition tools were successfully integrated into the HTC comprehensive clinic workflow, and 85% of eligible patients completed the assigned assessments. Utilization of MyChart is low, and access to MyChart was a frequently selected goal. Further work is underway to increase MyChart utilization which would facilitate workflow changes such that assessments may be completed in MyChart before the visit and educational and other resources can be accessed in MyChart. Achievement of patient goals, improvements in knowledge (e.g. how to read a prescription), and successful transfer are being tracked over time. Disclosures Thornburg: Sanofi Genzyme: Other: Data Safety Monitoring Board; Sanofi Genzyme: Research Funding; NovoNordisk: Research Funding; Genentech: Speakers Bureau; Bluebird bio: Other: Data Safety Monitoring Board; Ironwood: Other: Data Safety Monitoring Board.
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Mitchell, David M. "Hospital Care and Medical Utilization After Discharge." Annals of Internal Medicine 155, no. 10 (November 15, 2011): 719. http://dx.doi.org/10.7326/0003-4819-155-10-201111150-00016.
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Meltzer, David O., and Jeanette W. Chung. "Hospital Care and Medical Utilization After Discharge." Annals of Internal Medicine 155, no. 10 (November 15, 2011): 719. http://dx.doi.org/10.7326/0003-4819-155-10-201111150-00017.
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Rachoin, Jean-Sebastien. "Hospital Care and Medical Utilization After Discharge." Annals of Internal Medicine 155, no. 10 (November 15, 2011): 720. http://dx.doi.org/10.7326/0003-4819-155-10-201111150-00018.
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Brotman, Daniel J., Romsai T. Boonyasai, and Amy Deutschendorf. "Hospital Care and Medical Utilization After Discharge." Annals of Internal Medicine 155, no. 10 (November 15, 2011): 720. http://dx.doi.org/10.7326/0003-4819-155-10-201111150-00019.
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Raman, Arun K. "Hospital Care and Medical Utilization After Discharge." Annals of Internal Medicine 155, no. 10 (November 15, 2011): 721. http://dx.doi.org/10.7326/0003-4819-155-10-201111150-00020.
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Levin, Dimitriy, and Jeffrey J. Glasheen. "Hospital Care and Medical Utilization After Discharge." Annals of Internal Medicine 155, no. 10 (November 15, 2011): 721. http://dx.doi.org/10.7326/0003-4819-155-10-201111150-00021.
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Freeman, Joshua. "Hospital Care and Medical Utilization After Discharge." Annals of Internal Medicine 155, no. 10 (November 15, 2011): 721. http://dx.doi.org/10.7326/0003-4819-155-10-201111150-00022.
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Kuo, Yong-Fang, and James S. Goodwin. "Hospital Care and Medical Utilization After Discharge." Annals of Internal Medicine 155, no. 10 (November 15, 2011): 722. http://dx.doi.org/10.7326/0003-4819-155-10-201111150-00023.
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Lin, Yen-Ju, Chun-Chih Chen, Tsai-Ching Liu, and Ying-Tzu Lin. "Addiction and the Utilization of Medical Care." Economics Research International 2012 (November 30, 2012): 1–10. http://dx.doi.org/10.1155/2012/801204.
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We investigate the effect of different scales of addictive factors on the utilization of medical services in this paper using a two-part model. Data are from the 2005 National Health Interview Survey and the claims data in the National Health Insurance Research Database in Taiwan. The results show that personal addictive behavior is significantly associated with both outpatient and inpatient utilization. Moreover, our result implies that those who smoked at least 20 cigarettes per day might not visit a doctor until the illness was severe. It suggests that the government can accomplish these goals by promotion and education in order to increase public awareness of personal health.
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Ballas, Samir K., William F. McCarthy, Robert L. Bauserman, Oswaldo L. Castro, Myron A. Waclawiw, and Bruce A. Barton. "Sickle Cell Genetic Markers: Geographic Distribution and Relation to Pain Outcomes in Multicenter Study of Hydroxyurea in Sickle Cell Anemia." Blood 114, no. 22 (November 20, 2009): 2582. http://dx.doi.org/10.1182/blood.v114.22.2582.2582.
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Abstract Abstract 2582 Poster Board II-559 Introduction: Genetic markers related to the severity of outcomes in sickle cell disease include β-globin cluster haplotypes; X-chromosome-linked F-cell production loci; and the number of α-globin genes. Patients in the Multicenter Study of Hydroxyurea (MSH), a randomized, double-blind, placebo-controlled trial of hydroxyurea (HU) treatment in sickle cell anemia, provided samples for genotyping. We examined the relationship between these markers and demographic characteristics; geographic distribution across MSH sites; HU treatment response; and pain outcomes including rate of painful crises; pain intensity; frequency of pain at home; frequency of at-home analgesic usage; frequency of medical contacts; and equianalgesic dosing at home and during hospital contacts. Patients and Methods: Subjects were n=299 patients enrolled in MSH. Patients came from 21 sites across 14 U.S. states and 1 Canadian province, with 5 to 57 enrolled at each site. The sample was almost equally males and females, ages 18 to 57 (with an average of 30) at entry, with a minimum of 3 painful crises in the previous year and a diagnosis of sickle cellanemia.Genetic markers examined were β-goblin haplotype (Central African Republic/CAR, Benin/BEN, Sengal /SEN, Cameroon /CAM, and atypical), X-linked loci, and α-globin genes. Patients kept two-week diaries in which they recorded daily pain levels on a 0-9 scale; whether or not they used opioids that day; and whether or not any unscheduled medical contacts took place. The use of specific opioids and the doses taken were recorded by providers at biweekly follow-up visits and also during medical contacts; these were converted into equianalgesic doses, which were used to obtain total and average daily doses for the two-week follow-ups and average daily doses for those medical contacts involving ER utilization or in-patient admission. Fetal hemoglobin (Hb F) was measured at baseline and again at 18-21 months after treatment initiation; ‘responders' were defined as patients with Hb F levels below 15% at baseline but above 15% at 18-21 months (the 15% level was selected based on prior research and treatment recommendations). Results: The only sex difference found in relation to genetic markers was higher values for x-linkage in females (p=.002). Geographically, sites were clustered into 2 regions (Northern/Southern) based on climate. The number of α-globin genes was higher in Northern sites than Southern (p=.039); β-haplotypes and X-linkage did not differ across regions.HU treatment responders, shown elsewhere to have better outcomes in terms of painful crisis rates and other pain variables, differed significantly from nonresponders only in X-linkage (p=.006), with stronger X-linkage associated with being a responder. For pain outcomes, there were no significant relationships between β-haplotypes or α-globin genes and rate of painful crises, average pain scores at home, the frequency of days with pain, days with analgesic use, or unscheduled medical visits. X-linkage was marginally (p=.06) associated with medical visits; stronger x-linkage was associated with fewer medical visits. For equianalgesic dosing, significant associations were found with α-globin genes and the CAM haplotype. More α-globin genes were associated were lower at-home total and daily dosing and with lower daily doses of both oral and parenteral analgesics in hospital; however, further exploration by sex indicated that all of these associations were significant for males only (all p's<.05 for males, >.05 for females). The presence of the CAM haplotype was associated with higher in-hospital oral and parenteral dosing and higher at-home total and daily dosing, but all associations were again significant for males only (p's<.05). Conclusions: Some genetic markers known to play a role in sickle cell disease were associated with classification as a treatment responder, pain-related outcomes, and equianalgesic dosing in the MSH cohort. However, when examined by sex, associations with equianalgesic dosing were statistically significant for males only. There is a need for further in-depth exploration of the role that genetic markers play in sickle cell pain outcomes, and in particular examination of possible sex differences and testing of potential explanations for those differences. Disclosures: No relevant conflicts of interest to declare.
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Tomari, Tsutomu, Tsuguo Yanagihashi, Ichiro Wakisaka, Hiromichi Hatano, Virgilio de Asa, Bhupendra Pathik, Jai Ram Balgovind, and Masami Satoh. "Pattern of Medical Care Services Utilization in Fiji." Asia Pacific Journal of Public Health 4, no. 1 (January 1990): 18–24. http://dx.doi.org/10.1177/101053959000400104.
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The present study was designed to analyze sociodemographic and health related factors that influence the utilization of medical care services in Fiji by using the method of discriminant function. Some sociodemographic and health related independent variables had significant effects on the two patterns of modern and traditional medical services utilization. Discriminant function coefficients for sex, age and race are large enough to suggest the importance of discriminating between two patterns of medical care utilization. This suggests that traditional medical service is coexistent with modern medicine in Fiji and might play an extremely important role in providing health care for rural communities in the same way as modern medicine.
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Dickinson, Edward T., Vincent P. Verdile, Timothy Duncan, and Kerry A. Bryant. "Managed care enrollee utilization of 911 medical services." Prehospital Emergency Care 3, no. 4 (January 1999): 321–24. http://dx.doi.org/10.1080/10903129908958962.
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Orme-Johnson, D. "Medical care utilization and the transcendental meditation program." Psychosomatic Medicine 49, no. 5 (September 1987): 493–507. http://dx.doi.org/10.1097/00006842-198709000-00006.
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Alvey, Justin C., Karen Valentine, Jacob Wilkes, Tyler Bardsley, Colleen Marty, Kilby Mann, and Nancy A. Murphy. "Indirect Care Utilization Among Children with Medical Complexity." Current Physical Medicine and Rehabilitation Reports 7, no. 1 (March 2019): 1–5. http://dx.doi.org/10.1007/s40141-019-0204-6.
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Hankin, Cheryl S., Avron Spiro, Dorcas Mansell, Donald R. Miller, and Lewis E. Kazis. "Mental Disorders and Medical Care Utilization of VA Ambulatory Care Patients." Journal of Ambulatory Care Management 29, no. 1 (January 2006): 51–60. http://dx.doi.org/10.1097/00004479-200601000-00006.
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Klepser, Michael E., and Donald G. Klepser. "The Dynamics of Health Care Resource Utilization." Pharmacotherapy 22, no. 2 Part 2 (February 2002): 39S—44S. http://dx.doi.org/10.1592/phco.22.4.39s.33656.
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Karkoska, Kristine Anne, Kevin E. Todd, Kelly Clapp, Lynette Fenchel, Theodosia A. Kalfa, Punam Malik, Omar Niss, Charles T. Quinn, Russell E. Ware, and Patrick T. McGann. "Increased Hydroxyurea Prescribing Practices over Ten Years with Improved Clinical Outcomes in Children with Sickle Cell Anemia: A Single Center's Experience." Blood 136, Supplement 1 (November 5, 2020): 34. http://dx.doi.org/10.1182/blood-2020-138754.
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Introduction: Sickle cell anemia (SCA) is a severe and life-threatening disorder that requires treatment to prevent short- and long-term complications and prolong life. The primary disease-modifying therapy for SCA remains hydroxyurea (HU). Due to 30 years of evidence demonstrating safety and efficacy culminating with BABY HUG, the 2014 National Heart, Lung, and Blood Institute (NHLBI) guidelines recommended offering HU to all children with the severe sickle cell genotypes (HbSS, HbS-0thalassemia) beginning at 9 months of age. Despite these recommendations, HU utilization in pediatric patients in the US remains with rates reported as low as 38-47% among the most severe genotypes as recently as 2017. Providers have identified a number of barriers to more widespread use, including the inability to identify which patients may benefit, concern for possible side effects, uncertainties regarding dose, and concerns regarding possible nonadherence. As complications begin as early as the first year of life, it is a disservice to withhold a proven therapy. Here, we describe the effective and nearly universal uptake of HU in our pediatric SCA population at Cincinnati Children's Hospital Medical Center (CCHMC). Methods: We performed an IRB-approved retrospective review to assess the hydroxyurea prescribing practices and clinical complications of patients with SCA treated at CCHMC from 2010-2019. Following the NHLBI guidelines' release in 2014, we changed the recommended age of HU initiation to be within the first year of life. Corresponding with this change, we have initiated HU for most young children with an individualized, pharmacokinetics (PK)-guided dosing strategy through both the Therapeutic Response Evaluation and Adherence Trial (TREAT, NCT03789591) and the Hydroxyurea Optimization through Precision Study (HOPS, NCT03789591). Due to the onset of symptoms for some patients before 9 months, we have offered HU initiation as early as 6 months of age since 2015. Our objective was to compare the rates of HU utilization, age of initiation, and hospitalization rate before (2010-13) and after (2014-19) the release of the NHLBI guidelines and the start of the TREAT study in 2014. Demographic and clinical data, including sickle cell genotype, prior/alternative therapy, SCA-related complications, HU dosing, and laboratory values were abstracted from each patient's electronic medical record (EMR). Patients were identified using the EMR's sickle cell registry. Results: We identified 439 patients with sickle cell disease followed at CCHMC from 2010-2019 (47% female, age range: 0-22 years); 275 had SCA (HbSS, HbS-0-thalassemia, or HbSD). The proportion of patients with SCA prescribed HU increased from 2010-19, from 35% in 2010 to 80% in 2019 with significantly more patients initiating HU during 2014-19 versus 2010-13 (average 20 versus 12 patients/yr, p = 0.0028, Figure 1A). The age of HU initiation was significantly lower during 2014-19 compared to 2010-13 (median = 2 y vs 6 y, p = 0.00028). Of 35 patients with SCA not on HU in 2019, 28 received chronic transfusions and the remaining 7 received no disease-modifying therapy with 3/7 patients not yet at the age to start HU. Ninety-six percent (53/55) of children with SCA born during 2014-19 were on treatment, including 52 on HU (median starting age = 10 months) and 1 on chronic transfusions; 45/52 (87%) were enrolled on TREAT or HOPS. With increased HU utilization during this study period, the number of admissions for sickle-related events was significantly lower in the 2014-19 group versus 2010-13 (2.8 vs 6.9 admissions/pt, p = 9.0 x 10-10) with no change in non-SCA related admissions, most commonly for fever (3.8 vs 4.0 admissions/pt, p = 0.8, Figure 1B). Conclusions: HU has become the standard of care for children with SCA, beginning at 6-9 months of age, prior to the onset of acute and chronic complications. Despite widespread concerns that HU will not be accepted by patients and national trends demonstrating low rates of utilization, we have shown that a deliberate, systematic, and preventive approach to HU is possible and results in nearly universal acceptance of HU for young patients with SCA. This has translated to excellent laboratory responses and significantly fewer SCA-related clinical complications in our population. Our approach and improved patient outcomes can serve as a model for other programs to expand their HU treatment for more children with SCA. Figure 1 Disclosures Kalfa: Agios Pharmaceuticals, Inc: Consultancy, Research Funding; Forma Therapeutics, Inc: Research Funding. Malik:Aruvant Sciences, CSL Behring: Patents & Royalties; Aruvant Sciences, Forma Therapeutics, Inc.: Consultancy.
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Singh, J. A., and V. Strand. "Health care utilization in patients with spondyloarthropathies." Rheumatology 48, no. 3 (October 17, 2008): 272–76. http://dx.doi.org/10.1093/rheumatology/ken472.
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Crowder, D. "Reduction of Health Care Costs by Utilization of High Quality Medical Care." DMW - Deutsche Medizinische Wochenschrift 134, S 08 (November 2009): S324. http://dx.doi.org/10.1055/s-0029-1242679.
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Eaker, E. "Alzheimer's Disease or Other Dementia and Medical Care Utilization." Annals of Epidemiology 12, no. 1 (January 2002): 39–45. http://dx.doi.org/10.1016/s1047-2797(01)00244-7.
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Jennings, Donna L., and Shelley I. White-Means. "Medical Care Utilization by AFDC Recipients Under Reformed Medicaid." Journal of Health & Social Policy 13, no. 2 (June 2001): 21–39. http://dx.doi.org/10.1300/j045v13n02_02.
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Dunn, Abe, Eli Liebman, and Adam Hale Shapiro. "Implications of Utilization Shifts on Medical-care Price Measurement." Health Economics 24, no. 5 (March 4, 2014): 539–57. http://dx.doi.org/10.1002/hec.3036.
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Hearld, Larry R., Kristine R. Hearld, and Claudia Guerrazzi. "Patient-Centered Medical Home Capacity and Ambulatory Care Utilization." American Journal of Medical Quality 32, no. 5 (November 16, 2016): 508–17. http://dx.doi.org/10.1177/1062860616677319.
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The patient-centered medical home (PCMH) has increasingly received attention as a model of care to potentially remedy the cost and quality problems that confront the US health care system, including and especially ambulatory care–related issues. This study examined the association between physician practices’ PCMH capacity and 3 indicators of ambulatory care utilization: (1) emergency department utilization, (2) ambulatory care sensitive hospitalization rate, and (3) 30-day all-cause readmission rate. Results show that overall PCMH capacity is associated with lower rates, and technical aspects of the PCMH in particular were associated with lower utilization rates while interpersonal capabilities were not.