No description available.

Ambulatory surgery centers (ASCs) play an important role in providing surgical and diagnostic services in an outpatient setting. They can be owned by physicians who staff them. Previous studies focused on patient “cherry picking” and over-utilization of services due to physician ownership. Few studies examined the relationship between physician ownership and quality of care. Using a retrospective cohort of patients who underwent colonoscopy, this study examined the effect of physician ownership of ASCs on the occurrence of adverse events after outpatient colonoscopy. Agency theory is used to as a conceptual framework. Depending on the extent to which consumers are able to assess quality of care differences across health care settings, physician ownership can function as a mechanism to improve quality or as a deterrent to quality. Four adverse event measures are used in this study: same day ED visit or hospitalization, 30-day serious gastrointestinal events resulting in ED visit or hospitalization, 30-day other gastrointestinal events resulting in ED visit or hospitalization, and 30-day non-gastrointestinal events resulting in ED visit or hospitalization. Physician ownership status is determined based on a court decision in California in 2007. Data sources include the State Ambulatory Surgery Databases (SASD), State Inpatient Databases (SID), Emergency Department Databases (SEDD), State Utilization Data Files, the Area Resource File (ARF), and HMO/PPO data from Health Leaders. After controlling for confounding factors, the study found that colonoscopy patients treated at a physician-owned ASC had similar odds of experiencing same day ED visit or hospitalization and 30-day non-gastrointestinal events resulting in ED visit or hospitalization as those treated in a hospital-based outpatient facility. But the former had significantly higher odds of experiencing 30-day serious gastrointestinal events and 30-day other gastrointestinal events resulting in ED visit or hospitalization. The results are robust to changes in propensity score adjustment approach and to the inclusion of a lagged quality indicator. They suggest that physician ownership of ASCs was not associated with better quality of care for colonoscopy patients. As more complex procedures are shifted from hospital-based outpatient facilities to ASCs, expanded efforts to monitor and report quality of care will be worthwhile.

ABSTRACT ASSESSING BASELINE AND POST-DISCHARGE RISK FACTORS IN SUBJECTS WITH AND WITHOUT SLEEP APNEA UNDERGOING ENDOSCOPY WITH DEEP SEDATION Background: Outpatient procedures encompass over 60% of all surgeries in the United States, and the prevalence of obstructive sleep apnea (OSA) remains high among adult surgical ambulatory patients. Ambulatory surgery poses problems for patients with OSA because narcotics and anesthetics used during surgery can complicate the negative effects of OSA, leading to cardiac events, brain hypoxia, and even death. This study was designed to evaluate the prevalence of cardiopulmonary risk factors among post endoscopic patients with diagnosed and undiagnosed sleep apnea. Methods: The study involved a prospective, descriptive cross-sectional design and incorporated a pre-test or post-test data collection approach, using Actigraphy, pulse oximetry and 24-hour ECG monitoring via Bluetooth technology to monitor outpatients undergoing endoscopy with deep Propofol sedation. Patients were recruited pre-procedure to obtain a resting baseline ECG, and pre-procedure values were then monitored post procedure continuously for 24 hours. A p-value less than 0.05 was considered to be statistically significant. A target sample included 50 adult outpatients from a Florida suburban endoscopy center. Results: Pulse oximetry and Actigraph scores revealed no difference based on OSA. The ANOVA for oxygen desaturation events and sleep quality indices reflected no differences across groups. Sleep quality had no measurable influence on adverse events and was similar across groups; participants diagnosed with OSA slept longer than those in the untreated or no OSA group. Regressions for sleep quality indices reflected no differences among groups. Conclusions: There remains a lack of literature on cardiopulmonary and ECG indicators of cardiac risks in patients with OSA in the 24 hours following discharge from ambulatory surgery. This dissertation characterized the ECG at baseline and post-discharge among post-endoscopy outpatients with OSA and without OSA. Further research is recommended.

No description available.

No description available.

Background: The World Health Organization (WHO) recommends the community-based Outpatient Therapeutic Program (OTP) as a standard treatment protocol for the management of uncomplicated Severe Acute Malnutrition (SAM) at the community level. OTP has been scaled up and integrated into the existing grassroots level government health systems in several developing countries. The aim of this thesis was to assess the implementation and outcome of a scaled-up and integrated OTP service provided at community level. Methods: One qualitative study and three quantitative studies were conducted in southern Ethiopia. Children admitted to 94 integrated OTPs, their caregivers and health extension workers providing primary health care services in the nearby health posts were included in this study. The quantitative studies were based on data generated from observation of a cohort of 1,048 children admitted to the integrated OTPs. Result: On admission 78.8% of the children had SAM. The majority of these children 60.2% exited the program neither achieving program recovery criteria nor being transferred to inpatient care. Fourteen weeks after admission to OTP, 34.6% were severely malnourished and 34.4% were moderately malnourished, thus 69.0% were still acutely malnourished. Ready-to-use Therapeutic Foods (RUTFs) provided for SAM children were commonly shared with other children in the household and sold as a commodity for the collective benefit of the family thus admitted children received only a portion of the provided amount. Further, the program suffered a severe shortage of RUTFs, where only  46.6% of admitted children were given the recommended amount of RUTFs by providers on admission and only 34.9% of these had uninterrupted provision during the follow-up. Conclusion: The integrated OTPs we studied provide a constrained service and the use of RUTFs by families is not as intended by the program. The majority of admitted children remained acutely malnourished after participating in the program for the recommended duration. For integrated OTPs to be effective in chronically food-insecure contexts, interventions that also address the economic and food needs of the entire household are essential. This may require a shift to view SAM as a symptom of broader problems affecting a family rather than as a disease of an individual child. In addition, further research is needed to understand the health system context regarding RUTFs and medication supply and service utilization of integrated OTPs.

The Doctor Interactive Group Medical Appointment (DIGMA) is a group health intervention that combines the services of behavioral health and primary care. The DIGMA was first invented by Edward Noffsinger in 1996, in response to his own difficulties with the overtaxed primary care system at Kaiser Permanente in California (Noffsinger, 1999). Integrating healthcare services in this way has practical implications such as efficient use of resources, treating multiple complaints at once, and beginning to view the mind and body as one (Noffsinger, 1999; Engel, 1977). The DIGMA at the Austin Veterans Outpatient Clinic was designed to address the specific needs of veterans with hypertension. It consists of 4 sessions of 1.5 hours each and addresses such varied topics as exercise, stress-management, nutrition, and medication adherence. These topics are discussed in a group format with the tenets of group psychotherapy (Yalom & Leszcz, 2005) as a backdrop. An exploratory study was warranted to determine whether programs of this sort would be effective on a broad scale. A pretest/posttest design was utilized to determine if the DIGMA was effective at reducing symptoms of hypertension; improving health promoting behavior; increasing self-efficacy to manage hypertension; and increasing internal health locus of control while decreasing chance and powerful others health locus of control. Groups were conducted over a period of seven months with a total of 73 male veterans enrolled in the study. The final n was 58. Findings indicated that both systolic and diastolic blood pressure readings were reduced significantly from pretest to posttest. Health promoting behavior increased significantly; hypertension self efficacy increased significantly; and locus of control did not change significantly from pretest to posttest. The exploratory study concluded that the DIGMA may be efficacious for a variety of aspects of the management of hypertension. It is suggested that further research be conducted but that integrating services in this way can lead to improved patient outcomes and can also be cost-effective. / text

Approximately 65% of all surgeries are conducted in the outpatient surgery setting involving more than 35 million patients. Thirty-five to fifty percent of these outpatients will experience post discharge nausea and vomiting (PDNV), nausea and vomiting that occurs after discharge from the health care facility after surgery. A dearth of literature details the problems associated with nausea and vomiting experienced by patients after discharge home from outpatient surgery. The purposes of this dissertation were to (1) review the current knowledge in the area of post discharge nausea and vomiting; (2) present results of an integrative review of the research literature to determine best evidence for prevention of PDNV in adults or rescue of patients who suffer from post discharge nausea and vomiting (PDNV); (3) present a critical review and analysis of measurement of nausea and vomiting after discharge from outpatient surgery, and (4) present findings of a prospective research study. The purposes of the research study were to: 1) describe the incidence and severity of PDNV over a 7-day period in a sample of adult surgical patients undergoing outpatient surgeries under general anesthesia, 2) describe the pharmacologic and nonpharmacologic modalities of care used by patients with PDNV to manage it, 3) compare the incidence and severity of PDNV between those who do and do not use pharmacologic and nonpharmacologic modalities, and 4) determine outcomes associated with PDNV. This study was part of a multi-site study that had as a primary objective development of a simplified risk model for predicting patients most likely to suffer PDNV. In this research study we described the incidence and severity of PDNV in adult outpatients after ambulatory surgery, described the pharmacologic and nonpharmacologic modalities of care used by patients with PDNV to manage it, compared the incidence and severity of PDNV between those who do and do not use pharmacologic and nonpharmacologic modalities, and determined outcomes associated with PDNV.

Disertacijoje nagrinėjama depresija sergančių moterų gyvenimo kokybė ir jos kitimas trejų metų ambulatorinio depresijos gydymo laikotarpiu, kaip veiksniai, galintys padėti įvertinti psichikos sveikatos paslaugų vartotojų išteklius, svarbius sveikatai užtikrinti bei kuriant efektyvesnes sveikatos apsaugos ir gydymo strategijas. Empirinėje darbo dalyje pristatomas moterų gyvenimo kokybės kitimo trejų metų ambulatorinio depresijos gydymo laikotarpiu, tyrimas, atliktas Kauno m. Šančių Psichikos sveikatos centre. Trejuose tyrimo etapuose dalyvavo 62 moterys. Šio tyrimo rezultatai atskleidžia, kad depresija sergančių moterų susirgimo pradžios amžius, gretutinių somatinių ligų buvimas, amžius, mokamo darbo turėjimas ir šių rodiklių sąveikos, susiję su gyvenimo kokybės vertinimu. Išanalizavus rezultatus nustatyta, kad per pirmuosius ambulatorinio depresijos gydymo metus moterims vyksta teigiami gyvenimo kokybės pokyčiai, o per antrus- trečius gydymo metus moterų gyvenimo kokybė nesikeičia arba blogėja, tačiau po trejų gydymo metų yra geresnė nei gydymo pradžioje. Nustatyta, kad po vienerių metų gydymo pasiektas pasveikimas yra reikšmingiausias veiksnys, lemiantis didesnius teigiamus gyvenimo kokybės pokyčius, kiti svarbūs veiksniai - mažesnis depresijos klinikinių rodiklių kiekis ir/arba išreikštumas bei socialiniai ir demografiniai veiksniai (jaunesnis amžius, gyvenimas su partneriu, žemesnis išsilavinimas). Tyrimo rezultatai patvirtino, jog teigiami gyvenimo kokybės pokyčiai... [toliau žr. visą tekstą] / Depressive women’ quality of life and its changes during three years of the outpatient treatment is analyzed in this study. This study looks deeper into the factors which are helpful in assessment of recourses enhancing efficiency of mental health services and providing for better treatment and health protection strategies on behalf of the users of those services. The longitudinal panel survey of changes in women’ quality of life during three years of outpatient treatment of depression (in Kaunas city, Sanciu mental health center) is presented in the empirical part of the dissertation. 62 women participated in 3 screenings. The results of research show that more positive evaluation of the quality of life is related to the following factors: the older age of the beginning of the illness, absence of co morbid somatic illness, patient’s older age, having a paid job and interactions of these factors. Positive changes in quality of life occur during the first year of outpatient treatment of depression, while during the second-third year of treatment women’ quality of life remains stable or worsens, but after three years it becomes again better than in the initial screening. It is found that the recovery after one year of treatment is the most significant factor predicting more positive changes in the quality of life, while other important factors are: smaller number or less expressed clinical indicators of depression and social and demographic indicators (younger age, living with... [to full text]

Depressive women’ quality of life and its changes during three years of the outpatient treatment is analyzed in this study. This study looks deeper into the factors which are helpful in assessment of recourses enhancing efficiency of mental health services and providing for better treatment and health protection strategies on behalf of the users of those services. The longitudinal panel survey of changes in women’ quality of life during three years of outpatient treatment of depression (in Kaunas city, Sanciu mental health center) is presented in the empirical part of the dissertation. 62 women participated in 3 screenings. The results of research show that more positive evaluation of the quality of life is related to the following factors: the older age of the beginning of the illness, absence of co morbid somatic illness, patient’s older age, having a paid job and interactions of these factors. Positive changes in quality of life occur during the first year of outpatient treatment of depression, while during the second-third year of treatment women’ quality of life remains stable or worsens, but after three years it becomes again better than in the initial screening. It is found that the recovery after one year of treatment is the most significant factor predicting more positive changes in the quality of life, while other important factors are: smaller number or less expressed clinical indicators of depression and social and demographic indicators (younger age, living with... [to full text] / Disertacijoje nagrinėjama depresija sergančių moterų gyvenimo kokybė ir jos kitimas trejų metų ambulatorinio depresijos gydymo laikotarpiu, kaip veiksniai, galintys padėti įvertinti psichikos sveikatos paslaugų vartotojų išteklius, svarbius sveikatai užtikrinti bei kuriant efektyvesnes sveikatos apsaugos ir gydymo strategijas. Empirinėje darbo dalyje pristatomas moterų gyvenimo kokybės kitimo trejų metų ambulatorinio depresijos gydymo laikotarpiu, tyrimas, atliktas Kauno m. Šančių Psichikos sveikatos centre. Trejuose tyrimo etapuose dalyvavo 62 moterys. Šio tyrimo rezultatai atskleidžia, kad depresija sergančių moterų susirgimo pradžios amžius, gretutinių somatinių ligų buvimas, amžius, mokamo darbo turėjimas ir šių rodiklių sąveikos, susiję su gyvenimo kokybės vertinimu. Išanalizavus rezultatus nustatyta, kad per pirmuosius ambulatorinio depresijos gydymo metus moterims vyksta teigiami gyvenimo kokybės pokyčiai, o per antrus- trečius gydymo metus moterų gyvenimo kokybė nesikeičia arba blogėja, tačiau po trejų gydymo metų yra geresnė nei gydymo pradžioje. Nustatyta, kad po vienerių metų gydymo pasiektas pasveikimas yra reikšmingiausias veiksnys, lemiantis didesnius teigiamus gyvenimo kokybės pokyčius, kiti svarbūs veiksniai - mažesnis depresijos klinikinių rodiklių kiekis ir/arba išreikštumas bei socialiniai ir demografiniai veiksniai (jaunesnis amžius, gyvenimas su partneriu, žemesnis išsilavinimas). Tyrimo rezultatai patvirtino, jog teigiami gyvenimo kokybės pokyčiai... [toliau žr. visą tekstą]