Appendix in back pocket / xi, 284 leaves : / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (M.D.)--University of Adelaide, based on a study conducted in the Dept. of Social and Preventive Medicine, Monash University, 1973

Background: Long outpatient waiting time is a significant problem in Mainland China’s healthcare system. Long patient waiting time negatively affects actual care quality as well as patients’ perceptions of medical care. Aim: This study aims to understand the causes of long patient wait times in China’s outpatient care departments, and how those waits influence patients’ attitudes towards medical care. The rhythm of hospital patient flow will be explored in order to posit modest suggestions to resolve these issues. Objectives: The objectives of this study are to identify the causes of long waiting times in China’s outpatient care departments, to distinguish the specific bottleneck points in patient flow, and to characterize the relationship between waiting time length and the patients’ perceptions of medical care. Method: Two tertiary care hospitals in Mainland China were included as study sites. Macroergonomic methodologies were adopted to guide the data collection and analysis. The Systems Engineering Initiative for Patient Safety (SEIPS) model was specifically adopted to guide the study design and data analysis procedures. First, audio records were made of interviews with care providers from the two hospitals in order to document and discern the causes of long outpatient care waiting times. Second, a time study was carried out with patients visiting two outpatient departments at the two study sites in order to identify inefficiencies and bottleneck points in the patient flow. Third, a questionnaire survey was provided to the patients in order to understand the impact of lengthy wait times on their overall perceptions of medical care. The interview data was analyzed using content analysis methods, time study data was used to generate a patient flow model, and the questionnaire feedback was analyzed in tandem with the time study data using a linear regression analysis. Results: Sixty-three factors contributing to lengthy patient wait time were discerned from the interview data, concerning each of the five dimensions of the SEIPS model work system. Two patient flow diagrams were designed based on identified patient flow inefficiencies and bottlenecks. A majority (four-fifths and three-quarters, respectively, at the two study sites) of total patient visit time was spent on waiting for physician services and ancillary, non-medical activities. Serious bottlenecks in patient flow occurred while waiting for physician consultation, ultrasound examinations, and medical test result feedback. Patients’ evaluations of medical care quality dropped 0.04 points for each minute of consultation wait time, and 0.02 points for each minute of total visit duration and total waiting time. Conclusions: The causes of long patient wait times concern the physicians’ and patients’ characteristics, the organization and management of the hospital, the tasks, technology, and tools involved, and the hospital environment. Waiting for physician consultation, ultrasound examinations, and medical test result feedback cause the most patient flow problems. Long wait times have an adverse impact upon patients’ perceptions of medical care. The macroergonomic methodologies prove feasible and effective in evaluating health care systems. / published_or_final_version / Industrial and Manufacturing Systems Engineering / Master / Master of Philosophy

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Magistro baigiamajame darbe analizuojama nepakankamai veiksmingo gydymo ambulatorinėmis sąlygomis ir su juo susijusio gydytojų nurodymų nesilaikymo problema. Darbo tikslas – nustatyti nedrausmingo gydymosi ambulatorinėmis sąlygomis proporcijas ir galimas priežastis tarp LSMUL Kauno klinikų Nefrologijos skyriuje stacionarizuotų pacientų, kuriems ambulatorininėmis sąlygomis taikytas gydymas nebuvo pakankamai veiksmingas. Tyrimo metu nustatyta, kad didžiajai daliai stacionarizuotų pacientų ambulatorinis gydymas nebuvo pakankamai veiksmingas. Įvertinta, kad daugiau negu du trečdaliai šių pacientų vaistus vartojo nedrausmingai. Nepakankamos žinios apie ligą, motyvacijos trūkumas, užmiršimas išgerti vaistus arba jų nutraukimas esant gerai savijautai – būdingi daugiau negu trečdaliui nedrausmingų pacientų. Tai rodo, jog, atsižvelgiant į aukštus nepakankamai veiksmingo ambulatorinio gydymo rodiklius, paciento apsilankymo pas sveikatos priežiūros specialistą metu, tikslinga atkreipti dėmesį į paciento vaistų vartojimo ypatumus. Užtikrintas ir aiškus pacientų informavimas apie nesigydymo riziką bei nedrausmingumo problemos akcentų diegimas socialinėje erdvėje galėtų prisidėti prie naujo požiūrio į paciento atsakomybę už savo sveikatos būklę formavimo, teigiamų gydymo rezultatų suvokimo, demotyvacinių mechanizmų vystymosi mažinimo. / The study analyzes the problem of insufficiently effective outpatient treatment and the related problem of medication non-adherence. The aim of the study is to investigate, among patients hospitalized in the nephrology sector, both the prevalence of non-adherence and the possible causes for which their ambulatory treatment was not sufficiently effective. It was found that majority of outpatient treatment cases were not sufficiently effective. It is estimated that more than two-thirds of these patients were non-adherent. The inadequate knowledge about the disease, lack of motivation, forgetfulness and discontinuation of drug use when feeling well were incident to over than one third of non-adherent patients. This suggests that, given the high rates of insufficiently effective outpatient treatment, it is appropriate to draw attention to the patient's medication-use peculiarities. Moreover, informing the patient about possible threats of non-adherence and a more social implementation of the treatment may help the patients to understand the positive results of the treatment and reduce the development of their demotivating mechanisms.

Class of 2014 Abstract / Specific Aims: To determine the prevalence of metabolic syndrome (MetS) in patients treated in an outpatient clinic that were taking atypical antipsychotics. Methods: This retrospective chart review included 822 adults diagnosed with various personality/mood disorders. Age, gender, ethnicity, blood pressure, height, weight, lipid panels, fasting blood glucose, and second-generation antipsychotic (SGA) used and treatment length were obtained. Patients were separated into two groups: those who were not taking an SGA in/for the past three months (group 1), and those taking at least one SGA for a minimum of three months (group 2). MetS was determined using NCEP ATP III guidelines. The primary outcome measured was the difference in the prevalence of MetS between each group. Main Results: At baseline, 753 patients were in group 1 and 69 patients were in group 2, there was a higher percentage of females in group 1 (p<0.0001), and a higher percentage of males in group 2 (p<0.0001). No difference was seen with age, and weight, (p=0.294, p=0.625, respectively). There were more patients reported as Caucasian in group 2 (p=0.0001) and more reported as Caucasian/Hispanic in group 1 (p=0.0001). The rate of MetS between group 1 (54.45%) and group 2 (59.42%) was not statistically different (p = 0.427). Conclusion: No statistical difference was found in the rate of MetS between the two groups. Removing confounding drugs known to cause weight gain did not change these results.

Class of 2006 Abstract / Objectives: To assess the accuracy of medication histories taken upon hospital admission. Methods: This study was a prospective chart review comparing the accuracy of hospital admission medication histories with outpatient pharmacy and physician records. Eleven hundred patients admitted to El Dorado Hospital were eligible for participation. Patients were excluded if they were: under 18 years old, non-English speaking, in a room with precautions, transferred from a hospital or skilled nursing facility, unable to give oral consent, or admitted to a geri-psychiatric unit. After verification of medication, dose, and schedule with outpatient pharmacy and physician records, the findings were documented as perfect agreement, error of omission, or error of commission. Results: One hundred and nineteen patient histories were analyzed. Forty three patients (36%) had at least one error in their medication history. Of the 582 medications verified for accuracy, 491 medications were accurate and 91 errors were identified. Of the errors identified, 64 were errors of commission and 27 were errors of omission. The average age of patients who had at least one error type was 74.9 years, and the average age of patients who did not have any errors was 68.3 years (p = 0.004). Medication histories with six or more medications were more commonly associated with errors (p = 0.001). There was no relationship between medication history errors and specific classes of medications such as cardiovascular, lipid-lowering, and antidiabetic agents. Conclusions: Medication histories for patients older than 75 years or those that contain six or more medications are more likely to contain an error. There appears to be no link between medication class and occurrence of error. While this study does not address methods to reduce error rates, verification of medication histories with outpatient pharmacies and physicians may help reduce hospital medication errors and promote positive health outcomes.

Purpose: Use of ampicillin in outpatient parenteral antimicrobial therapy (OPAT) has historically been complicated by frequent dosing and short beyond use dates. However historic stability data relied on inaccurate testing methods. The purpose of this study is to evaluate the stability of ampicillin using high-pressure liquid chromatography (HPLC), the gold standard, in a real-world OPAT dosing model using continuous infusion at room temperature over 24 hours immediately following preparation compared to batches stored under refrigeration for 24 hours, 72 hours, and 7 days. Methods: An HPLC method was developed and validated as stability – indicating according to guidance in USP general Chapter . Method development included linearity, precision, accuracy, repeatability and forced degradation. Four batches were prepared using 4 different lots from 2 different manufacturers for each storage condition (immediate, 24 hours, 72 hours, and 7 days). Three 2-gram vials were each reconstituted with 10 mL of sterile water for injection (SWFI) and added to 250 mL of normal saline by a licensed pharmacist and stored in a laboratory refrigerator (2 – 8oC). A pump system was used to continuously circulate the solutions through medical grade tubing at room temperature. One milliliter aliquots were removed from each batch at time 0, 4 hours, 8 hours, 12 hours and 24 hours and analyzed for ampicillin concentration using the aforementioned HPLC method. The samples were filtered prior to analysis using a 0.22-micron syringe filter and analyzed in triplicates along with freshly prepared calibration samples (24 – 12 mg/mL). Peak area was used to determine percent recovery for each sample. Results: Each batch was assayed for initial concentration (20.34 – 21.50 mg/mL) upon preparation, and percent recovery was compared to that initial concentration thereafter. Acceptable recovery was defined as 90 – 110% of initial concentration. On the day of product preparation (immediate use), the average percent recovery over 24 hours was 96.4%. The other average percent recoveries were as follows: 95.8% (24-hour storage), 94.6% (72-hour storage) and 90.3% (7-day storage). These data represent the average percent recovery for all time points during the 24 hours sampling (n = 60 for each experiment). When evaluating individual time points, the percent recovery remained above 90% for all batches and time points except for the 7-day storage experiment. Under 7-day storage conditions, the percent recovery fell below 90% after 4 hours of circulation through the medical grade tubing. Furthermore, 95% confidence interval for percent recovery for ampicillin in the samples stayed within 90 – 110% of the initial concentration for the duration of the experiment for all test groups except 7-day storage. Conclusions and Relevance: Ampicillin can be prepared and stored in a refrigerator for up to 72-hours prior to continuously infusing at room temperature over 24 hours with less than a 10% loss of potency over the dosing period. This model supports twice weekly OPAT delivery of ampicillin.

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