This diploma thesis deals with the solution to a real situation that occurred at Nemocnice Na Františku in Prague. The problem is solved by using a computer simulation in SIMUL8 simulation program. At the beginning I describe the theoretical foundations that are afterwards used as a basis for the main practical part. The main subject of the work is a simulation of an operation of the hospital outpatient department. The hospital management decided to change the system for handling patients operations. I have created simulation models for particular workday and weekend means of patients serving operations. The created simulation models and their outputs are evaluated in the final part of the thesis and will serve as a basis for making reorganization decisions in the hospital. The provided advice for hospital management fulfills the goal of this thesis.

Class of 2007 Abstract / Objectives: This 12-month retrospective, naturalistic study determined medication adherence, psychiatric hospitalizations, cost of services, cost of prescriptions, and rates of polypharmacy (less than 4 versus greater than or equal to 4 concomitant psychotropic medications) for patients receiving clozapine versus quetiapine therapy for the treatment of schizophrenia in an outpatient mental health facility. Methods: The clozapine and quetiapine groups were compared for gender, age, medication adherence rates, hospitalizations, cost of care, polypharmacy, and types of concomitant psychotropic medications over 12-months. The polypharmacy groups for clozapine and quetiapine (e.g., greater than or equal to 4 psychotropic medications versus less than 4 psychotropic medications) were compared for medication adherence. Results: A total of 71 patients met the entry criteria (44 = clozapine and 27 = quetiapine). The two groups were similar for age, gender, court order, average daily dose, and hospitalization rates. The clozapine group had a higher medication adherence rate of 0.901 (e.g., 329 days supply) compared to the quetiapine group’s adherence rate of 0.723 (e.g., 264 days supply) (p=0.007). The clozapine group had higher costs for medication, labs, and other services compared to the quetiapine group, as well as total costs of services (p=0.004). The clozapine group was on fewer concomitant psychotropic medications compared to the quetiapine group based on the rates of polypharmacy. Conclusions: Patient on clozapine therapy had improved medication adherence and lower rates of polypharmacy, but higher costs of care compared to quetiapine. The frequent monitoring required with clozapine may result in medication adherence that results in improved efficacy, less polypharmacy, and lower hospitalization rates. Further studies in larger populations are needed to compare different frequency rates of monitoring patients on outcome measures over a longer period of treatment.

Introdução. A ansiedade é um sentimento normal que prepara o organismo para situações adversas. É difícil de ser quantificada, porém pode ser estimada por meio de escalas subjetivas como a analógica visual, a comportamental e a verbal ou de maneira objetiva indireta por meio de parâmetros hemodinâmicos ou quantificação de hormônios do estresse no plasma ou na saliva. Cirurgias realizadas sob regime ambulatorial acarretam menor custo e menor índice de infecção hospitalar. No entanto, não existem dados suficientes para afirmar que a não internação hospitalar provoca menor grau de ansiedade nos pacientes. Objetivo. Quantificar e comparar mediante a utilização de escalas, questionários e dosagem do cortisol salivar, o grau de ansiedade de pacientes submetidas a cirurgias sob regime ambulatorial ou sob regime de internação. Casuística e método – Foram constituídos dois grupos de 12 pacientes cada um: grupo RA no qual as pacientes foram operadas eletivamente sob regime ambulatorial e grupo RI no qual as pacientes foram operadas eletivamente sob regime de internação. Todas as pacientes foram avaliadas quanto ao estado de ansiedade na véspera e no dia da cirurgia por meio da aplicação das escalas de Spielberger (traço e estado), verbal e analógica visual e da quantificação do cortisol salivar. Avaliou-se ainda o comportamento hemodinâmico. A coleta da saliva foi realizada em dois momentos: na véspera e no dia da cirurgia. Saliva para quantificação do cortisol foi coletada no sétimo e oitavo dias pós-operatório para avaliação do ritmo basal das pacientes. Resultados. Os dados demográficos entre os dois grupos, considerando idade e peso, mostraram-se estatisticamente idênticos. Em relação ao padrão hemodinâmico, não houve diferença entre os dois grupos de regime de internação na véspera da cirurgia. No dia da cirurgia, o grupo RA apresentou pressão arterial diastólica maior do que o grupo RI. Nos demais parâmetros hemodinâmicos (pressão arterial sistólica e freqüência cardíaca) não houve diferença entre os grupos. A avaliação da ansiedade verificada por meio da Escala Verbal não evidenciou diferença entre os grupos na véspera e no dia da cirurgia, enquanto que, no dia da cirurgia, as pacientes do regime ambulatorial apresentaram, na Escala Analógica Visual, escores de ansiedade maiores que as pacientes do regime de internação. Na escala de Spielberger, o traço-ansiedade encontrado nos grupos foi similar e o estado-ansiedade, na véspera da cirurgia, foi maior no grupo operado sob regime ambulatorial. Não houve diferença entre os grupos no tocante ao cortisol salivar. Conclusão. Pacientes operadas sob regime ambulatorial apresentaram maior grau de ansiedade do que as pacientes operadas sob regime de internação. / Introduction. Anxiety is a normal feeling that prepares the organism for adverse situations. It is hard to quantify, but can be estimated through subjective scales like the visual analogue, behavioral and verbal scales or in an indirect objective way, using hemodynamic parameters or quantification of stress hormones in plasma or saliva. Outpatient surgeries entail lower costs and hospital infection rates. However, there is no sufficient data to affirm that non hospitalization provokes lower anxiety levels in patients. Objective. To quantify and compare anxiety levels between patients submitted to outpatient or inpatient surgery using scales, questionnaires and salivary cortisol measurement. Methods. We constituted two groups with 12 patients each: group RA, in which patients were subject to elective outpatient surgery and group RI, in which patients were hospitalized for elective surgery. All patients were assessed for anxiety on the evening before and on the day of surgery by applying Spielberger’s state-trait anxiety, the verbal and visual analogue scales and by quantifying salivary cortisol. We also evaluated hemodynamic behavior. Saliva samples were collected at two times: on the evening before and on the day of surgery. Saliva for cortisol measurement was collected on the seventh and eighth day after surgery to evaluate patients’ baseline rhythm. Results. When considering age and weight, demographic data were statistically identical between both groups. On the evening before surgery, no differences were found in terms of hemodynamic standards. On the day of surgery, we found higher diastolic blood pressure for group RA than for group RI. No differences were found between both groups for other hemodynamic parameters (systolic blood pressure and heart rate). The results of the Verbal Scale did not show any difference in anxiety between the groups, neither on the evening before nor on the day of surgery. When using the Visual Analogue Scale, outpatients presented higher anxiety scores than inpatients on the day of surgery. On Spielberger’s scale, trait-anxiety in both groups was similar, while outpatients revealed higher state-anxiety on the evening before surgery. No differences were found in salivary cortisol levels. Conclusion. Patients operated on in an outpatient regime present higher anxiety levels than patients hospitalized for surgery.

Despite generous universal social health insurance with little formal restrictions of outpatient utilisation, Austria exhibits high rates of avoidable hospitalisations, which indicate the inefficient provision of primary healthcare and might be a consequence of the strict regulatory split between the Austrian inpatient and outpatient sector. This paper exploits the considerable regional variations in acute and chronic avoidable hospitalisations in Austria to investigate whether those inefficiencies in primary care are rather related to regional healthcare supply or to population characteristics. To explicitly account for inter-regional dependencies, spatial panel data methods are applied to a comprehensive administrative dataset of all hospitalisations from 2008 to 2013 in the 117 Austrian districts. The initial selection of relevant covariates is based on Bayesian model averaging. The results of the analysis show that supply-side variables, such as the number of general practitioners, are significantly associated with decreased chronic and acute avoidable hospitalisations, whereas characteristics of the regional population, such as the share of population with university education or long-term unemployed, are less relevant. Furthermore, the spatial error term indicates that there are significant spatial dependencies between unobserved characteristics, such as practice style or patients' utilization behaviour. Not accounting for those would result in omitted variable bias.

ABSTRACT Background: Alcohol use disorders (AUD) affect health and wellbeing, and have broad societal costs (Bouchery, Harwood, Sacks, Simon, & Brewer, 2011; Rehm et al., 2009; Sudhinaraset, Wigglesworth, Takeuchi, & Tsuker, 2016). While treatments have existed for decades, they are limited in success and expensive to administer. As such, understanding which factors best predict who will benefit most from treatment remains a laudable goal. Prior attempts to predict factors associated with positive treatment outcome are limited by methodology including statistical methods that lead to poor predictive power in new samples. This study aims to use a data-driven approach to clarify the predictors of AUD treatment success (Objective 1) accompanied by a theory-driven analysis assessing the mediation of treatment outcomes through psychological distress (Objective 2). Methods: One hundred forty-five patients seeking treatment for alcohol use problems at the Day One Intensive Outpatient Treatment Program (part of UVM Medical Center) between June 2011 and June 2012 were examined. Variables were extracted through chart review and were categorized using the Bronfenbrenner Ecological Model. First, 20% of the sample was set-aside for model testing, and the remaining 80% was used in an Elastic Net Regularized linear regression, with 10-fold cross validation. Models were tested on the set-aside sample to yield estimates of out-of-sample prediction and repeated models were compared to ensure generalizability. Next, a theoretical model was tested examining a model of psychological distress mediating the relationship between individual predictors and treatment outcome. Results: The models developed from the Elastic Net Regularization approach demonstrated consistency in model strength (mean=0.32, standard deviation=0.03) with models ranging from 14 to 31 included variables. Across the models, 15 variables occurred in >75% of the models, and an additional 7 variables were included in 25% - 75% of the models. Some of the strongest predictors included treatment non-compliance (β=-0.92), ASI Alcohol Composite (β=0.63), treatment dosage (β =-0.36), and readiness to change (β=-0.95). The results of the theory-driven mediation analysis demonstrated several strong direct predictors of outcome frequency of alcohol use, including readiness to change (β=-0.59), initial frequency of alcohol use (β=0.27), and access to a primary care physician (β=-2.20). The theoretical model found that none of the mediation pathways (testing psychological variables) were significantly different from the direct models. Conclusions: This study used both data-driven and theory-driven methods to examine factors affecting treatment of AUDs. The application of data-driven methods provided several predictors of outcome that can guide treatment efforts within Day One IOP treatment, as well as generalized to other abstinence-based treatment settings. For example, focusing on treatment attendance and using motivational interviewing to enhance readiness to change are methods supported by this study. Demographic variables that have been shown to predict treatment outcome in small studies, without cross-validation were not identified by the elastic net regression (e.g., age and gender). It is suspected that this is due to model overfitting in prior studies supporting the importance of using generalizable statistical methods to understand predictors of treatment outcome. This notion is supported by the results of the theory-driven model, which did not yield a strong model of treatment success. Taken together, the results support the use of strong analytic techniques which will guide theory in the future.

Dual diagnosis clients continue to have low treatment completion rates. The purpose of the current study was to understand if motivational interviewing helped to increase completion rates for clients receiving cognitive behavioral therapy (CBT). Studying the problem was necessary for identifying an evidenced-based model for mental health counselors to help clients with dual diagnoses complete CBT treatment. There were no studies available for understanding the effectiveness of motivational interviewing as a tool for improving treatment completion rates for dual diagnoses clients in intensive outpatient programs. The research question examined if motivational interviewing was effective for improving treatment completion rates for the dual diagnosis population. A quantitative methodology with a quasi-experimental design used for this study and included a paired samples t test, a chi-square test, and a logistic regression analysis. The results showed a statistically significant association between receiving the motivational interviewing techniques and completing CBT. Clients who received motivational interviewing were 4 times more likely to complete CBT treatment compared to clients who did not receive the technique. Clients with increased self-efficacy levels were 2 times more likely to complete treatment, thus addressing the problem of dual diagnosis clients having low treatment completion rates. The overall results demonstrated that clients reduced substance use relapse and recidivism improved. Completing treatment helped to reduce crimes related to drug use; it also prepared substance users for return to society as productive citizens, which promoted positive social change.

People living with heart failure (PLHF) should be screened for symptoms at every healthcare visit since they are 3 times more likely to experience ventricular arrhythmias. This quality improvement project (QIP) compared 3 self-administered HF symptoms questionnaires to determine the best screening tool for a tertiary hospital arrhythmia devices clinic. The instruments included the Minnesota Living with Heart Failure Questionnaire (MLHFQ), the Kansas City Cardiomyopathy Questionnaire (KCCQ), and the Self-Reported Heart Failure Symptoms (SHEFS) questionnaire. For a 30-day period, 76 people were eligible to participate in the QIP, with 55 participants included in the final analysis (72.5% participation). The questionnaires were compared and assessed with the gold standard laboratory test for HF (NT-proBNP) for sensitivity and specificity. For HF, the SHEFS was the most sensitive (83%) compared to the NT-proBNP, but the MLHFQ was most specific (89%). When compared to the MLHFQ as the standard, SHEFS was 71% sensitive, and 73% specific for HF. Similarly, when compared to the KCCQ, the SHEFS was both, 75% specific and sensitive in identifying HF. However, the rate of correlation to a positive or negative NT-proBNP test results was the highest for the SHEFS (87%). All 3 questionnaires were statistically significant in predicting admission to hospital for HF in the past 6 months (p = 0.02 to 0.03). Finally, given the shortest length and simplicity of use, the SHEFS was selected by the stakeholders to be the standard screening tool for the clinic. This project contributes to positive social change by providing the first reported comparison in the literature to implement questionnaires in a clinic to assess symptoms for PLHF attending an arrhythmia devices clinic.

This project explored the challenges confronting clinicians who work with the Assertive Community Treatment Program (ACT), a government-sponsored clinic-based program providing services for individuals with persistent and recurrent mental health challenges in a large metropolitan city in the southern United States. The project involved semi-structured interviews with 15 health care clinicians to explore what they perceived as challenges and their recommendations for addressing them. Themes were organized around the 6 dimensions of the the relationship-based care model: leadership, teamwork, professional nursing, care delivery, resources, and outcomes. Identified patient challenges included transportation, lack of health insurance, housing, acceptance of certified peer specialists, the stigma of seeking help for mental health issues, problems with tracking patients, family interference, and fear of discharge from the program. Challenges related to the work environment were identified as poor pay for mental health staff, increasing paper work, professional boundaries, and balancing work demand and personal experiences. Recommendations to address challenges included open communication, interdisciplinary meetings to improve coordination of resources, increased support for family participation, and community support for mental health services. This project adds to the knowledge on ACT programs and will assist organizations planning or delivering ACT services in channeling resources to areas recommended by ACT clinicians. Recommended organizational changes will provide a positive social change to improve care of individuals with mental health challenges in the community.

<p><p><strong>Syfte:</strong> Syftet med denna studie är att bland patienter med långvarig smärta, som är remitterade till en smärtmottagning, undersöka förväntningar avseende det första besöket, i vilken utsträckning patienterna anser att dessa uppfylldes samt att undersöka vilka förväntningar patienterna har på den fortsatta vården och kontakten med Smärtmottagningen. <strong>Metod:</strong> En empirisk studie med kvalitativ deduktiv ansats. Datainsamling skedde genom att tio personer intervjuades på Smärtmottagningen efter deras första besök. Materialet bearbetades med manifest innehållsanalys.<strong> Resultat:</strong> Patienter vid Smärtmottagningen hade i olika stor utsträckning förväntningar inför det första besöket och den fortsatta vården. Patienterna ansåg i varierande utsträckning att deras förväntningar på det första besöket hade uppfyllts, dock uttryckte alla patienter att minst någon förväntning uppfyllts. Gällande den fortsatta vården förväntade sig patienterna bland annat smärtlindring, stöd samt att upprätta en kontakt med Smärtmottagningen. <strong>Slutsats:</strong> Patienter vid en smärtmottagning har förväntningar på vården och att känna till dessa kan underlätta mötet med patienten för sjukvårdspersonalen. Föreliggande studie ger en inblick i tio patienters förväntningar och huruvida de blivit uppfyllda och tyder på att det är av värde att fråga patienter om deras förväntningar. Detta är något som smärtmottagningar kan överväga att implementera i vården.</p></p> / <p><p><strong>Aim:</strong> The aim of this study was to investigate expectations on the first appointment among patients with chronic pain referred to an outpatient pain clinic. The aim was also to investigate to which extent the expectations on the first appointment were fulfilled and to investigate the patients’ expectations on the continuing care and contact with the outpatient pain clinic.<strong> Method: </strong>An empirical study with qualitative design was used. The data was collected through interviews with ten patients after their first appointment at the clinic. Data was processed using manifest content analysis.<strong> Result:</strong> The patients had expectations in various extents prior to their first appointment and on the further care. The patients thought that their expectations were fulfilled to various extent, however all patients expressed that at least one expectation had been fulfilled. Regarding the continuing care the patients expected, among other things, to receive functioning pain treatment and support as well as to establish a contact with the outpatient pain clinic.<strong> Conclusion:</strong> Patients have expectations and awareness of these among the medical staff might facilitate the meeting between the medical staff and the patient. This study provides an insight in ten patients’ expectations and to which extent they have been fulfilled. The study also suggests that it would be of value to ask patients about their expectations, which outpatient pain clinics can consider implementing.</p></p>

The 2001 Institute of Medicine's (I.O.M.) landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century observes that, "[though] medical science and technology have advanced at a rapid pace,...the health care delivery system has floundered in its ability to provide consistently high-quality care" (I.O.M. 2001). The report recommended six quality aims for a twenty-first century health care system; one of them being patient-centered care. It explains patient-centered care as "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions" (I.O.M. 2001). This research is aimed at directly addressing this I.O.M. recommendation and seeks to understand quality care in the context of the I.O.M. guideline which clearly states that to achieve quality "the patient is the source of control of interactions" with the provider system. The objectives of this project are: (i) to gain a deeper and clearer understanding of the ways patients as customers of an outpatient clinic evaluate health care providers, and (ii) to determine if varying definitions of service quality exist with in a clinic containing a complex constituency. The project site chosen was the set of outpatient clinics at USF Health that makes for a complex site (e.g. eighty different specialties, outpatient surgical units, practicing and academic environment, multi-disciplinary teams at work involving multiple levels of health care professionals and complex inter-personal relationships) to carry out this research. The formal hypothesis can be stated as follows: H1: There exist identifiable differing classes of patients with varying perceptions of Service Quality in an outpatient setting. The subsequent research questions that the research aims to address are that, given that differing patient classes can be identified, do they have an impact on the overall patient-perceived quality and how significant is the impact? The project will contribute to a change in the approach at the clinic from a profession-centered to a patient-centered effort. It will raise the awareness among clinicians about how patients view quality care which can then be integrated into the system, institutionalized over time and thus help them improve their ability to provide quality care as preferred by patients. It will also serve to educate and empower the patients by increasing their participation and strengthening their role as partners with clinicians in a health care system. According to a review of the consumer health literature (Hibbard 2003), patients who collaborate with their health care providers and play an active role in their health care have improved health outcomes. It also enables future work in metric identification to promote continuous improvement in care provision. Though the research was conducted at a specific outpatient setting, it will have wider applicability as it can be a model worth emulating more broadly. The study also contributes to the academic literature that clearly indicates that there is a recognized need for more research on the delivery of outpatient care (Hammons 2003). Additionally, the study can be applicable and useful in other environments with complex constituencies (e.g. university classrooms, public transportation and travel industry).