Authors: Anna E Dion, James Roake, Kate Mayeda...

Free clinics are a widespread, yet limited research has examined the health status of people served and the cost effectiveness of free clinics. The purpose of this study was to describe the sociodemographic characteristics and prevalence of chronic conditions in patients seen at a free clinic and estimate the clinic's cost-effectiveness. The study was a retrospective chart review of 350 randomly selected paper medical charts (2009-2020) and 1,676 electronic medical records (2020-2022) at the Noor free clinic in California supported by private donors, non-profits, and foundations. Cost-effectiveness was calculated from annual clinic operating costs, services provided, quality-adjusted life years (QALYs) saved, and projected savings from preventing emergency department visits. Of the 350 paper charts reviewed, 336 met inclusion criteria. Patients had an average age of 46.6 years, with most identifying as female (60%), Hispanic (69%), Spanish-speaking (62%), and employed (59%). About 64% had incomes below the federal poverty line. Chronic conditions included overweight/obesity (75%), chronic pain (46%), hypertension (28%), hyperlipidemia (24%), type 2 diabetes (24%), and mood disorders (23%). A quarter of patients had at least one chronic condition, and over half had multiple conditions. The clinic's services in 2022 resulted in an estimated 146 QALYs saved, $11.5 million in cost savings, and a return on investment of $13.18 per $1 invested. The free clinic provided medical care to low-income, Hispanic populations without insurance who historically have been disenfranchised from healthcare access. Cost-effectiveness analysis suggested that it provided significant health benefits and cost savings.

Topics: Humans; Female; Male; Middle Aged; Retrospective Studies; Chronic Disease; Cost-Benefit Analysis; Adult; Prevalence; Ambulatory Care Facilities; California; Quality-Adjusted Life Years; Aged; Young Adult; Cost-Effectiveness Analysis

PubMed: 39425887
DOI: 10.1007/s10900-024-01417-7

Review

Authors: Laura Cosmai, Camillo Porta, Mark A Perazella...

Onconephrology is a rapidly evolving subspeciality that covers all areas of renal involvement in cancer patients. The complexity of the field may benefit from well-defined multidisciplinary management administered by a dedicated team. Since there is an increasing need to address the needs of this population in dedicated outpatient clinics, it is critical to highlight basic characteristics and to suggest areas of development. In this brief perspective article, we analyse the requirements of an onconephrology clinic in terms of logistics, critical mass of patients and building a multidisciplinary team. We will further discuss which patients to refer and which conditions to treat. The last part of the article is dedicated to education and performance indicators and to analysis of the potential advantages of applying the hub-and-spoke model to this field. The ultimate aim of this experience-based article is to initiate debate about what an onconephrology outpatient clinic might look like in order to ensure the highest quality of care for this growing population of patients.

Topics: Ambulatory Care Facilities; Humans; Interdisciplinary Communication; Kidney Neoplasms; Medical Oncology; Nephrology

PubMed: 29982771
DOI: 10.1093/ndt/gfy188

Authors: Taslima Mamataz, Sean A Virani, Michael McDonald...

OBJECTIVES

There are substantial variations in entry criteria for heart failure (HF) clinics, leading to variations in whom providers refer for these life-saving services. This study investigated actual versus ideal HF clinic inclusion or exclusion criteria and how that related to referring providers' perspectives of ideal criteria.

DESIGN, SETTING AND PARTICIPANTS

Two cross-sectional surveys were administered via research electronic data capture to clinic providers and referrers (eg, cardiologists, family physicians and nurse practitioners) across Canada.

MEASURES

Twenty-seven criteria selected based on the literature and HF guidelines were tested. Respondents were asked to list any additional criteria. The degree of agreement was assessed (eg, Kappa).

RESULTS

Responses were received from providers at 48 clinics (37.5% response rate). The most common actual inclusion criteria were newly diagnosed HF with reduced or preserved ejection fraction, New York Heart Association class IIIB/IV and recent hospitalisation (each endorsed by >74% of respondents). Exclusion criteria included congenital aetiology, intravenous inotropes, a lack of specialists, some non-cardiac comorbidities and logistical factors (eg, rurality and technology access). There was the greatest discordance between actual and ideal criteria for the following: inpatient at the same institution (κ=0.14), congenital heart disease, pulmonary hypertension or genetic cardiomyopathies (all κ=0.36). One-third (n=16) of clinics had changed criteria, often for non-clinical reasons. Seventy-three referring providers completed the survey. Criteria endorsed more by referrers than clinics included low blood pressure with a high heart rate, recurrent defibrillator shocks and intravenous inotropes-criteria also consistent with guidelines.

CONCLUSIONS

There is considerable agreement on the main clinic entry criteria, but given some discordance, two levels of clinics may be warranted. Publicising evidence-based criteria and applying them systematically at referral sources could support improved HF patient care journeys and outcomes.

Topics: Humans; Cross-Sectional Studies; Heart Failure; Ambulatory Care Facilities; Hospitalization; Surveys and Questionnaires

PubMed: 38485484
DOI: 10.1136/bmjopen-2023-076664

Authors: Oliver T Nguyen, SriVarsha Katoju, Erick E Pons...

OBJECTIVE

Primary care use helps reduce utilization of more expensive modes of care, such as the emergency department (ED). Although most studies have investigated this association among patients with insurance, few have done so for patients without insurance. We used data from a free clinic network to assess the association between free clinic use and intent to use the ED.

METHODS

Data were collected from a free clinic network's electronic health records on adult patients from January 2015 to February 2020. Our outcome was whether patients reported themselves as 'very likely' to visit the ED if the free clinics were unavailable. The independent variable was frequency of free clinic use. Using a multivariable logistic regression model, we controlled for other factors, such as patient demographic factors, social determinants of health, health status, and year effect.

RESULTS

Our sample included 5008 visits. When controlling for other factors, higher odds of expressing ED interest were observed for patients who are non-Hispanic Black, older, not married, lived with others, had lower education, were homeless, had personal transportation, lived in rural areas, and had a higher comorbidity burden. In sensitivity analyses, higher odds were observed for dental, gastrointestinal, genitourinary, musculoskeletal, or respiratory conditions.

CONCLUSIONS

In the free clinic space, several patient demographic, social determinants of health and medical conditions were independently associated with greater odds of reporting intent on visiting the ED. Additional interventions that improve access and use of free clinics (e.g., dental) may keep patients without insurance from the ED.

Topics: Adult; Humans; Ambulatory Care Facilities; Emergency Service, Hospital; Ill-Housed Persons; Safety-net Providers

PubMed: 37327708
DOI: 10.1016/j.ajem.2023.06.003

Review

Authors: Marie Evans, Kai Lopau

People with advanced chronic kidney disease and evidence of progression have a high risk of renal replacement therapy. Specialized transition clinics could offer a better option for preparing these patients for dialysis, transplantation or conservative care. This review focuses on the different aspects of such transition clinics. We discuss which patients should be referred to these units and when referral should take place. Patient involvement in the decision-making process is important and requires unbiased patient education. There are many themes, both patient-centred and within the healthcare structure, that will influence the process of shared decision-making and the modality choice. Aspects of placing an access for haemodialysis and peritoneal dialysis are reviewed. Finally, we discuss the importance of pre-emptive transplantation and a planned dialysis start, all with a focus on multidisciplinary collaboration at the transition clinic.

Topics: Ambulatory Care Facilities; Delivery of Health Care; Disease Progression; Humans; Patient Participation; Renal Dialysis; Renal Insufficiency, Chronic; Renal Replacement Therapy

PubMed: 32162667
DOI: 10.1093/ndt/gfaa022

Authors: Donald T Mhlungu, Geertien C Boersema, Mokholelana M Ramukumba...

BACKGROUND

 The delivery of quality primary healthcare (PHC) services is vital for enhancing the health status of rural communities, yet persistent barriers exist in resource-constrained rural settings.

AIM

 The study explored perspectives on the barriers to and facilitators of implementing the Ideal Clinic Realisation and Maintenance (ICRM) programme as a quality assurance initiative in a rural KwaZulu-Natal subdistrict.

SETTING

 Professional nurses and healthcare managers from seven PHC clinics in a rural subdistrict of KwaZulu-Natal and supervising managers from a district hospital participated in this study.

METHODS

 Telephonic semi-structured interviews were conducted using a qualitative case study approach with the purposively selected sample. Data were inductively and thematically analysed.

RESULTS

 Themes included ICRM programme organisation, barriers and facilitators for implementing the ICRM programme. Barriers in rural PHC settings included overburdened clinics, suboptimal infrastructure, staff burnout, poor communication and non-adherence to clinical guidelines. Despite obstacles, programme implementation was facilitated through stakeholder support and teamwork. Participants emphasised the need for infrastructure upgrades, more human and physical resources, and maintenance of stakeholder support.

CONCLUSION

 If challenges are mitigated and supportive factors are leveraged, the potential for successful programme implementation and improved healthcare delivery can benefit both healthcare providers and recipients.Contribution: Through providing insight into the perspectives of both implementers and supervisors, the study informs stakeholders and policymakers about difficulties encountered and potential improvements to be made in the implementation of the ICRM programme in rural PHC.

Topics: Humans; Rural Health Services; South Africa; Qualitative Research; Primary Health Care; Female; Ambulatory Care Facilities; Rural Population; Male; Quality Assurance, Health Care; Interviews as Topic

PubMed: 39501858
DOI: 10.4102/phcfm.v16i1.4586

Authors: Katherine Montag Schafer, Anne Keenan

For 5 years, our family medicine clinic's physician-pharmacy team managed anticoagulation onsite. Now, against our recommendations and desires as a clinic, anticoagulation at our site is no longer managed by our local interdisciplinary team. Instead, it is being managed by our system's centralized anticoagulation team. Although some may point out that anticoagulation management is one small element of our practice, we believe eliminating this could open the door to other changes to our scope of practice. Anticoagulation belongs in primary care where comprehensive care, ongoing relationships between patients and care teams, and flexible office visit agendas optimize this service.

Topics: Ambulatory Care Facilities; Anticoagulants; Humans; Office Visits; Primary Health Care; Warfarin

PubMed: 35879080
DOI: 10.1370/afm.2828

Review

Authors: Danielle A Lukish, Chantel I Cross, Megan E Gornet...

When a diverse group of individuals is working together in the contemporary fertility clinic to provide time-sensitive and complex care for patients, a high degree of coordination and collaboration must take place. When performed dynamically, this process is referred to as teaming. Although the positive impact of teamwork in health care settings has been well established in the literature, the concept of teaming has limited foundation in the clinic. This review will provide an overview of how teaming can be used to improve patient care in today's fertility clinics. Approaches to integrating teaming into the clinic that will be discussed include framing, the creation of a psychologically safe environment for staff input, and facilitating collaborative constructs to support teaming. Best practices to implement teaming and how to address challenges to teaming in today's clinical environment will also be addressed.

Topics: Ambulatory Care Facilities; Calibration; Delivery of Health Care; Female; Fertility Clinics; Humans; Male; Organizational Culture; Patient Care; Patient Care Team; Precision Medicine; Pregnancy

PubMed: 34753600
DOI: 10.1016/j.fertnstert.2021.09.032

Authors: Sara C Keller, Pranita D Tamma, Sara E Cosgrove...

INTRODUCTION

In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation.

METHODS

We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment.

RESULTS

Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS.

CONCLUSIONS

A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS.

Topics: Ambulatory Care; Ambulatory Care Facilities; Anti-Bacterial Agents; Antimicrobial Stewardship; Decision Support Systems, Clinical; Drug Resistance, Microbial; Ergonomics; Humans; Point-of-Care Testing; Quality Improvement; United States

PubMed: 29743225
DOI: 10.3122/jabfm.2018.03.170225

Authors: Grace Keegan, Amani Allen, Jordan Millhollin...

BACKGROUND

While student-run free clinics (SRFCs) play an important role in care for underserved populations, few mechanisms exist to promote collaboration among regional SRFCs.

AIMS

To address this gap, the Chicagoland Free Clinics Consortium (CFCC) was formed to (1) facilitate collaboration between Chicagoland SRFCs, (2) provide innovation grant funding, and (3) host an annual conference.

SETTING AND PARTICIPANTS

In 2018, students from the Pritzker School of Medicine founded the CFCC and partnered with peers from area schools to implement programming.

PROGRAM DESCRIPTION

Between 2018 and 2022, CFCC engaged 23 SRFCs representing all 6 Chicagoland schools, held 4 annual conferences, and distributed $15,423 in grants to 19 projects at 14 SRFC sites.

PROGRAM EVALUATION

A total of 176 students from 5 schools attended the 4 conferences. In 2022, 82 unique participants were surveyed, and 66% (54/82) responded. Eighty percent (43/54) reported they were "more likely to collaborate with other Chicagoland free clinics." In 2022, all grant sites were surveyed and 84% (16/19) responded. Most (87%,14/16) agreed the grant "allowed them to implement a project that would not have otherwise been accomplished" and 21% (4/19) were inter-institutional collaborations.

DISCUSSION

To our knowledge, CFCC is the first student-led organization to promote sustained collaboration across SRFCs in a metropolitan area.

Topics: Humans; Student Run Clinic; Program Evaluation; Cooperative Behavior; Medically Underserved Area; Students, Medical; Ambulatory Care Facilities

PubMed: 38286972
DOI: 10.1007/s11606-024-08637-6