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Ambulatory Care

AHRQ is committed to improving the safety and quality of ambulatory care in the United States. Ambulatory care is care provided by health care professionals in outpatient settings. These settings include medical offices and clinics, ambulatory surgery centers, hospital outpatient departments, and dialysis centers.

The scope of ambulatory care has expanded over the past decade, as the volume and complexity of interventions have expanded. Safe, high-quality ambulatory care requires complex information management and care coordination across multiple settings, especially for patients with chronic illnesses.

AHRQ's resources and tools improve the safety and quality of ambulatory care. They enhance the reliability of laboratory testing in medical offices; establish a culture of patient safety; improve the safety of care transitions; and identify techniques, tools, and strategies for clinicians to improve teamwork and performance. The Agency's resources also identify promising ambulatory care patient safety initiatives.

Ambulatory Surgery Center (ASC) Survey on Patient Safety Culture is a survey in the suite of AHRQ Surveys on Patient Safety Culture. The survey, designed specifically for ASC staff, asks for opinions about the culture of patient safety at their centers. The survey can raise staff awareness about patient safety, assess the status of patient safety culture, identify strengths and areas for improvement, examine trends, evaluate the cultural impact of patient safety initiatives and interventions, and conduct comparisons within and across organizations.

The Community-Acquired  Pneumonia Clinical Decision Support Implementation Toolkit helps clinicians and clinical informaticians in primary care and other ambulatory settings implement and adopt the community-acquired pneumonia (CAP) clinical decision support alert to identify the severity of a patient’s CAP and determine the appropriate site of care to manage it.

The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families is an ongoing project that offers four interventions and four case studies designed to improve patient safety by meaningfully engaging patients and families in their care.

Improving Your Office Lab Testing Process Ambulatory Toolkit  increases the reliability of the lab testing process within a medical office with step-by-step guidance. Includes checklists and materials to help communicate with patients.

The Medical Office Survey of Patient Safety Culture  is designed for outpatient medical office providers and staff. It asks their opinions about the culture of patient safety and health care quality in their medical offices.

Patient and Family Engagement in the Surgical Environment  features slide sets, facilitator notes, guides, tools, and videos help staff of ambulatory surgery centers engage patients and families in their care.

The Safety Program for End-Stage Renal Disease Facilities Toolkit  helps end-stage renal disease clinics prevent healthcare-associated infections in dialysis patients by following clinical practices, creating a culture of safety, using checklists and other audit tools, and engaging with patients and their families. The toolkit includes four instructional modules that a facilitator can use to teach dialysis center team members specific ways to create a culture of safety.

TeamSTEPPS ® for Office-Based Care  adapts the core concepts of the TeamSTEPPS program to reflect the environment of office-based medical teams. It offers techniques, tools and strategies to assist health care professionals develop and optimize team knowledge and performance in an office-based setting.

A Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings provides strategies, tools, and education to help staff who work in ambulatory care facilities prepare patients for new and follow-up appointments in order to prevent errors during transitions in care.

Internet Citation: Ambulatory Care. Content last reviewed February 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/settings/ambulatory/tools.html

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Definition of ambulatory

 (Entry 1 of 2)

Definition of ambulatory  (Entry 2 of 2)

• gallivanting
• galavanting
• perambulatory
• peripatetic

Examples of ambulatory in a Sentence

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'ambulatory.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

borrowed from Middle French & Latin; Middle French ambulatoire "movable, without fixed residence," borrowed from Latin ambulātōrius "movable, transferable, suitable for walking," from ambulāre "to go by foot, walk for pleasure or health, travel" + -tōrius, deverbal adjective suffix originally forming derivatives from agent nouns ending in -tōr-, -tor ; (sense 1b) after German ambulatorisch — more at amble entry 1

earlier ameltori, amlatorye, borrowed from Medieval Latin ambulātōrium, noun derivative from neuter of Latin ambulātōrius "movable, suitable for walking" — more at ambulatory entry 1

1598, in the meaning defined at sense 2

15th century, in the meaning defined above

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Cite this Entry

“Ambulatory.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/ambulatory. Accessed 15 Nov. 2023.

Kids Definition

Kids definition of ambulatory, medical definition, medical definition of ambulatory, legal definition, legal definition of ambulatory.

Latin ambulatorius , literally, movable, transferable, from ambulare to walk, move, be transferred

More from Merriam-Webster on ambulatory

Britannica English: Translation of ambulatory for Arabic Speakers

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Word of the Week: Ambulatory

Alex Dos Diaz / Verywell

Each week, Verywell explains a term from health, medicine, science, or technology.

How to say it :  Ambulatory ( am-byoo-la-tor-ee )

What it means : Able to walk about; not stuck in bed.

Where it comes from : From Latin, ambulātōrius, "suitable for walking."

Blend Images/JGI/Tom Grill/Getty

Where you might see or hear it : You might see the word "ambulatory" on a sign at a hospital or clinic. This type of care is also called " outpatient " because you do not need to be admitted to the hospital.

Getting a blood test at the lab or an imaging scan like an X-ray are a few examples of ambulatory care.

When you might want to use it : You may hear the word ambulatory or ambulate if you are in the hospital and healing after surgery . Your provider might tell you that you have to be "ambulatory" before you can be discharged.

You can tell your family that your provider said that you need to be able to safely get out of bed and walk a short distance—such as to the bathroom or down the hall—on your own before you can go home.

Merriam-Webster. Definition of ambulatory .

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Defining Ambulatory Care

Ambulatory care refers to medical services performed on an outpatient basis, without admission to a hospital or other facility (MedPAC). It is provided in settings such as:

• Offices of physicians and other health care professionals
• Hospital outpatient departments
• Ambulatory surgical centers
• Specialty clinics or centers, e.g., dialysis or infusion
• Urgent care clinics

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What is Ambulatory Care? Learning More About the Future of Healthcare

By Anna Heinrich on 09/19/2017

Today, you can have surgery on your gallbladder, knee or wrist and be back at home within hours, without ever having checked into a hospital. Fifty years ago, you could expect to be in the hospital for up to 10 days after delivering a baby. Now, you may be able to go home the same day. Crazy, isn’t it?

Same-day surgeries and services are the beginning of a new trend in healthcare: Ambulatory care. Also known as outpatient care, ambulatory services have been consistently on the rise. From 2000 to 2004, the percent of registered nurses working in ambulatory care grew five percent, while the percentage of registered nurses working in hospitals dropped four percent. This shift in the healthcare field affects you as a patient and as a future healthcare professional. But what is ambulatory care? We broke it down so you can understand what it is and why it is the future of healthcare.

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What classifies as ambulatory care?

Ambulatory care can be a misleading term, as it actually encompasses a wide range of care and services. By definition , ambulatory care is any same-day medical procedure performed in an outpatient setting. This refers to any medical service that is not performed in a hospital or facility that requires admission. We can further divide ambulatory care into four smaller sub-categories to better help you understand all that ambulatory care encompasses:

This is normally what you think of when you imagine going to the doctor. Ambulatory wellness services are mostly for prevention and basic medical care. They include doctor’s clinics, such as primary care, as well as counseling centers for mental health and weight loss.

Diagnostic services can be provided on their own, or as part of a wellness or treatment program. They include X-Rays, lab and blood tests, MRIs and screening for various cancers and illnesses.

These include same-day surgery centers, substance abuse clinics, chemotherapy and other forms of therapy.

Rehabilitation

Rehabilitation includes post-operative therapies, occupational and physical therapy and rehabilitation for drug and alcohol abuse. 

In addition to these procedures and services, ambulatory care encompasses newer forms of healthcare, such as telemedicine. Telemedicine allows doctors and nurses to “see” and interact with patients via email, phone and video-chatting. Amelia Roberts, BSN RN , uses telemedicine to assess her patients.

“Ambulatory care is different from hospital care in that my assessments happen via phone and email. My questions have to be very specific as I am not there to make vital observations,” Roberts says.

Who works in ambulatory care?

Ambulatory care, while outside of a hospital, employs almost all of the same healthcare professionals as inpatient care. Doctors, registered nurses, LPNs, physical therapists, physical therapy assistants, surgical techs, medical lab techs and medical administration staff can all be found in various ambulatory care settings.

While no further training or education is needed to work in an ambulatory care setting, nurses can specialize to become an ambulatory care nurse (ACN) . Nurses who work in ambulatory care often have more predictable schedules than nurses who work in hospitals. In addition, there are fewer emergencies and complications in outpatient care, making ambulatory care nursing perfect for nurses who don’t want the added stress of working in an emergency room or a large hospital.

How is ambulatory care shaping healthcare?

Hospitals are diverting many services to outpatient facilities. In 2008 , outpatient visits rose from 624 million to 675 million. So there’s no doubt that ambulatory care is growing and expanding into the traditional hospital space, but why and how does it affect patient care?

Justin Yeung, MD and CEO of ShareSmart , says, “Ambulatory care is growing in popularity because it is a money-saving measure for hospitals. Inpatient hospital stays are extremely costly and demand a lot of resources.”

To further that reasoning, Roberts says the current financial structure is “not sustainable” and compares current hospitalization costs and conditions to “a very expensive hotel room.” Ambulatory care offers hospitals a cost-effective alternative: They can provide the same services to patients at a fraction of the cost and in a fraction of the time.

With the implementation of the Affordable Care Act , hospitals have been pressed to cut costs and make healthcare more accessible and affordable to all. Ambulatory care provides a solution to both of these. As hospitals begin to turn to outpatient care, patients can expect to see a future of quick, same-day health services.

How does it affect you?

The increase in ambulatory care services and providers is a good thing for you as a patient and a future healthcare professional.

“Having worked in in-home care for many years, I can say that I would always prefer to work on an outpatient basis,” says Eddie Chu of Qualicare . “It addresses both physical and emotional needs and, therefore, provides a more attentive and well-rounded health service looking at the full picture.”

Besides more personalized care, patients who receive outpatient services are able to go home and resume their normal lives and activities more quickly. No overnight hospital stays means more time saved for patients and healthcare professionals alike.

In addition, the costs saved from having overnight stays reveals itself in lower medical bills. Doctors and nurses are also able to hold more routine schedules—no crazy overnights, and some who work in clinics may even have holidays and weekends off.

Be the future

As hospitals transition to more outpatient facilities, traditional healthcare positions will be shifting. According to the Bureau of Labor Statistics , employment in outpatient care centers is projected to grow 49 percent from 2014 to 2024. Where do you see yourself fitting into this new healthcare dynamic?

Now that you know more about what ambulatory care is and how it is shaping the future of healthcare, compare and contrast two of the most in-demand healthcare settings with our article, Acute Care vs. Ambulatory Care: Which Nursing Environment is Right for You? With so many nursing specialties and settings available, it’s worthwhile to look into all of your options, so you can excel in this exciting and changing field.

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Approximately 1% of primary care office visits are for chest pain, and 2% to 4% of these patients will have unstable angina or myocardial infarction. Initial evaluation is based on determining whether the patient needs to be referred to a higher level of care to rule out acute coronary syndrome (ACS). A combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease as the cause of chest pain. The Marburg Heart Score and the INTERCHEST clinical decision rule can also help estimate ACS risk. Twelve-lead electrocardiography is recommended to look for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new T-wave inversions. Patients with suspicion of ACS or changes on electrocardiography should be transported immediately to the emergency department. Those at low or intermediate risk of ACS can undergo exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging. In those with low suspicion for ACS, consider other diagnoses such as chest wall pain or costochondritis, gastroesophageal reflux disease, and panic disorder or anxiety states. Other less common, but important, diagnostic considerations include acute pericarditis, pneumonia, heart failure, pulmonary embolism, and acute thoracic aortic dissection.

Approximately 1% of all ambulatory visits in primary care settings are for chest pain. 1 Cardiac disease is the leading cause of death in the United States, yet only 2% to 4% of patients presenting to a primary care office with chest pain will have unstable angina or an acute myocardial infarction. 2 – 4 The most common causes of chest pain in the primary care population are chest wall pain (20% to 50%), reflux esophagitis (10% to 20%), and costochondritis (13%). 2 Other potential factors include pulmonary etiologies (pneumonia, pulmonary embolism [PE]), psychological etiologies (panic disorder), and nonischemic cardiovascular disorders (congestive heart failure, thoracic aortic dissection). 2 , 3 , 5 , 6 No definitive diagnosis may be found in as many as 15% of patients. 2 Differentiating ischemic from nonischemic causes is often challenging because patients with ischemic chest pain may appear well. As such, the initial diagnostic approach should always consider a cardiac etiology for the chest pain unless other causes are apparent. 7

Initial Evaluation

The first decision point for most physicians is to determine whether the patient needs immediate referral to the emergency department for further testing to determine whether the chest pain is an acute coronary syndrome (ACS) caused by coronary ischemia. 7 ACS is a clinical diagnosis that includes unstable angina, ST segment elevation myocardial infarction, and non–ST segment elevation myocardial infarction. Definitions of chest pain have evolved over time. Typical chest pain or angina is a deep, poorly localized chest or arm discomfort (pain or pressure) associated with physical exertion or emotional stress and relieved with rest or sublingual nitroglycerin within five minutes. 8 Unstable angina is new-onset angina, angina at rest, or angina that becomes more frequent, severe, or prolonged. 9 Acute myocardial infarction is myocardial injury resulting in elevated cardiac biomarkers in the setting of acute ischemia caused by ST segment elevation myocardial infarction or non–ST segment elevation myocardial infarction. 10 The impression of chest pain is often determined by a combination of clinical symptoms at the time of presentation, physical examination, initial electrocardiography (ECG), and risk factors for ACS. 11 Patients often do not use the term pain to describe their symptoms but frequently use other terms such as pressure, aching, discomfort, tightness, squeezing, or indigestion. 12

A meta-analysis of studies that evaluated the role of previous chest pain in diagnosing ACS concluded that chest pain that is pleuritic, positional, or reproducible with palpation and not related to exertion is low risk for ACS. Pain that is described as pressure (similar to that of prior myocardial infarction), worse than prior anginal pain, associated with exertion, accompanied by nausea or diaphoresis, and/or radiates to one or both arms/shoulders is higher risk for ACS. 13

Although individual characteristics generally do not support or rule out a diagnosis, a combination of these may increase diagnostic accuracy. 14 The combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease (CAD) as the cause of chest pain. 15 Table 1 outlines updated predicted pretest probabilities of CAD in patients with chest pain based on these three factors. 15 U.S. guidelines recommend that patients with a probability of less than 5% be classified as low risk and not undergo further testing. 16 Those with a probability greater than 70% should undergo invasive angiography, and those with a probability of 5% to 70% should undergo noninvasive testing. 16 European guidelines use cutoffs of 15% and 85%, respectively. 15

Validated clinical decision rules can help determine whether chest pain is caused by CAD. One systematic review found that the validated Marburg Heart Score is better than clinical judgment alone for predicting whether chest pain is cardiac in origin. 17 , 18 Table 2 outlines the scoring for this clinical rule and presents the probability of CAD as the cause of chest pain for pretest probabilities of 2%, 10%, and 20%. 18

The INTERCHEST clinical decision rule is a second validated decision rule that can predict the presence or absence of CAD in patients who present with chest pain in the primary care setting  ( Table 3 ) . 19 , 20 Patients with a score of less than 2 have only a 2% chance of having CAD, whereas 43% of patients with a score of 2 or more have CAD, making the test useful for ruling out CAD as a cause of the patient's chest pain. 20

Because history alone usually cannot determine whether a patient is actively experiencing cardiac ischemia, a 12-lead ECG should be performed on all patients in whom cardiac ischemia is suspected. 21 ECG findings that increase the likelihood of ACS include ST segment elevation, new-onset left bundle branch block, presence of Q waves, or new T-wave inversions. 22 Similar ECG findings may be observed in non-ACS conditions, including acute pericarditis and left ventricular hypertrophy. Patients with suspicion of ACS based on clinical presentation (history, physical examination, risk factors) with changes seen on ECG should be transported immediately to the emergency department. 16

For patients with chest pain not requiring immediate referral who have a low to intermediate pretest probability of CAD, exercise stress testing should be considered. 23 Adding myocardial perfusion or echocardiography to the stress test increases test accuracy with a negative predictive value for acute myocardial infarction and cardiac death of 98%. 24 Evaluating with coronary computed tomography angiography (CCTA) decreases the number of nonfatal acute myocardial infarctions 25 and is moderately more accurate than stress ECG in ruling out CAD in patients with chest pain (positive likelihood ratio [LR+] = 5.62; negative likelihood ratio [LR–] = 0.05). 26 As a result, CCTA is becoming a first-line test for patients presenting with chest pain in the emergency department and should be a consideration for family physicians evaluating and managing patients with stable chest pain in the office. Cardiac magnetic resonance imaging may be useful in the evaluation of typical angina. For the evaluation of acute chest pain, cardiac magnetic resonance imaging is comparable to angiography in mortality at one year; however, it results in less need for invasive angiography and fewer subsequent revascularization procedures. 27 Cost is a barrier to the use of CCTA and cardiac magnetic resonance imaging. According to Healthcare Bluebook, the cost of an exercise stress test is $171, whereas the price of CCTA is $667 and cardiac magnetic resonance imaging angiography is $1,075. 28 Consideration should also be given to the harms of radiation and contrast exposure from CCTA.

Other Diagnostic Considerations

If the initial evaluation indicates that ACS is less likely or the diagnostic evaluation for ACS in higher-risk patients is negative, other non-ACS conditions that may cause symptoms similar to coronary ischemia should be considered ( Table 4 ) . Understanding the presentation of these common conditions with the clinical impression will help lead to a correct diagnosis.

CHEST WALL PAIN

Chest wall pain is the most common cause of chest pain in the outpatient setting, accounting for 33% to 50% of chest pain. 29 One prospective cohort study identified four clinical factors that predict a final diagnosis of chest wall pain in patients presenting to the primary care office with chest pain: localized muscle tension, stinging pain, pain reproducible by palpation, and the absence of a cough. In a study population with a prevalence of chest wall pain of 47%, patients with at least two of these findings had a 77% likelihood of chest wall pain as the cause of their discomfort (LR+ = 3.02), and those with none or one of the findings had only an 18% likelihood (LR− = 0.47). 29

COSTOCHONDRITIS

Often considered a subset of chest wall pain, costochondritis is a self-limited condition characterized by pain that is reproducible with palpation in the parasternal costochondral joints. Costochondritis is a clinical diagnosis and does not require specific diagnostic testing in the absence of concomitant cardiopulmonary symptoms or risk factors. 30

GASTROESOPHAGEAL REFLUX DISEASE

Classic symptoms of gastroesophageal reflux disease (GERD) include a burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth. 31 , 32 There are no useful physical examination maneuvers or standard tests to establish the diagnosis or to support or rule it out. A one-week trial of a high-dose proton pump inhibitor is modestly sensitive and specific for GERD, with a 50% reduction in reflux symptoms being moderately accurate for a final diagnosis of GERD (LR+ = 5.5; LR− = 0.24). 33 ACS symptoms can often be mistaken for those of GERD; if clinical suspicion is high for ACS, an ECG should be obtained.

Panic Disorder and Anxiety State

Panic disorder and anxiety states are common. One in four people with a panic attack will have chest pain and shortness of breath. 34 Yet, concomitant panic disorder and chest pain are often not recognized, leading to more testing, follow-up, and higher costs of care. 34 A moderately accurate assessment for detecting panic disorder is had by asking the following validated screening question: “In the past four weeks, have you had an anxiety attack (suddenly feeling fear or panic)?” This question is good at supporting a diagnosis of panic disorder when patients answer yes (LR+ = 4.2) and is good at ruling it out when the answer is no (LR− = 0.09). 35

Less Common, but Important, Diagnostic Considerations

Pericarditis.

Pericarditis manifests as a clinical triad of pleuritic chest pain, a pericardial friction rub, and diffuse ECG ST–T-wave changes often preceded by a viral illness. 36 Acute pericarditis should be considered in patients presenting with new-onset chest pain that increases with inspiration or when reclining and is lessened by leaning forward. 36 ECG usually demonstrates diffuse ST segment elevation and PR interval depression.

Common symptoms of pneumonia include fever, chills, productive cough, and pleuritic chest pain. 37 Egophony (LR+ = 8.6), dullness to percussion of the posterior thorax (LR+ = 4.3), and respiratory rate greater than 20 breaths per minute (LR+ = 3.5) are suggestive of pneumonia. 38 Normal temperature, heart rate, and respiratory rate with a normal pulmonary examination rules out pneumonia (LR− = 0.10). 39 Chest radiography can assist in the diagnosis of pneumonia; however, a Cochrane review suggests that routine chest radiography does not affect outcomes in patients who present with signs of lower respiratory tract infection. 40

HEART FAILURE

Most patients with heart failure present with dyspnea on exertion, although some will present with chest pain. 41 Clinical impression is predictive of heart failure (LR+ = 9.9; LR− = 0.65), as is pulmonary edema on chest radiography (LR+ = 11.0). 41 Patients with acute dyspnea and one or more of the MICE criteria (Male sex, history of myocardial Infarction, basal lung Crepitations, and ankle Edema) likely have heart failure and should be evaluated with echocardiography. 42 , 43

PULMONARY EMBOLISM

Diagnosing PE in the office is challenging because its presentation is highly variable. Although dyspnea, tachycardia, and/or chest pain are present in 97% of those diagnosed with PE, no single clinical feature effectively supports or rules out its diagnosis. 44 Risk of PE can be estimated by using a validated clinical decision rule, such as the Wells criteria ( Table 5 ) . 45 Patients at moderate or higher risk should undergo additional testing with a d-dimer assay, ventilation-perfusion scan, or helical computed tomography of the pulmonary arteries. 45 The Pulmonary Embolism Rule-out Criteria were developed to specifically rule out PE in the primary care setting. 46 Patients meeting all eight criteria (50 years or younger, heart rate less than 100 beats per minute, oxygen saturation greater than 94%, no unilateral leg swelling, no hemoptysis, no surgery or trauma within four weeks, no previous deep venous thrombosis or PE, no oral hormone use) have a less than 1% likelihood of PE and thus do not need d-dimer testing or imaging. 46 , 47

ACUTE THORACIC AORTIC DISSECTION

Patients with acute thoracic aortic dissection may present with chest or back pain. 48 History and physical examination are only modestly useful for supporting or ruling out the diagnosis; acute chest or back pain and a pulse differential in the upper extremities modestly increases the likelihood of an acute thoracic aortic dissection (LR+ = 5.3). 49 Clinical suspicion for thoracic dissection warrants immediate referral to the emergency department.

This article updates previous articles on this topic by McConaghy and Oza 50 and Cayley . 51

Data Sources: A PubMed search was completed using the key terms chest pain, chest pain evaluation, diagnosis, clinical decision rule, differential diagnosis, acute coronary syndrome, and angina. The search included meta-analyses, reviews, randomized controlled trials, point-of-care guides, and clinical trials. We also searched the Cochrane Database of Systematic Reviews, the National Guideline Clearinghouse, Essential Evidence Plus, Database of Abstracts of Reviews of Effects, and Agency for Healthcare Research and Quality Evidence Reports. Search date: literature search was completed on several occasions; last date was October 11, 2020.

Rui P, Okeyode T. National ambulatory medical care survey: 2016 national summary tables. Accessed December 28, 2019. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf

Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract. 1994;38(4):345-352.

Will JC, Loustalot F, Hong Y. National trends in visits to physician offices and outpatient clinics for angina 1995 to 2010. Circ Cardiovasc Qual Outcomes. 2014;7(1):110-117.

Heron M. Deaths: leading causes for 2017. National Vital Statistics Reports. National Center for Health Statistics. June 24, 2019. Accessed January 8, 2020. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf

Svavarsdóttir AE, Jónasson MR, Gudmundsson GH, et al. Chest pain in family practice. Diagnosis and long-term outcome in a community setting [published correction appears in Can Fam Physician . 1996;42:1672]. Can Fam Physician. 1996;42:1122-1128.

Ebell MH. Evaluation of chest pain in primary care patients. Am Fam Physician. 2011;83(5):603-605. Accessed September 15, 2020. https://www.aafp.org/afp/2011/0301/p603.html

Kontos MC, Diercks DB, Kirk JD. Emergency department and office-based evaluation of patients with chest pain. Mayo Clin Proc. 2010;85(3):284-299.

Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA focused update of the guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [published corrections appear in Circulation . 2011;124(12):e337–e340 and Circulation . 2011;123(22):e625–e626]. Circulation. 2011;123(18):2022-2060.

Braunwald E. Unstable angina. A classification. Circulation. 1989;80(2):410-414.

Thygesen K, Alpert JS, Jaffe AS, et al.; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol. 2018;72(18):2231-2264.

National Clinical Guideline Centre for Acute and Chronic Conditions (UK). Chest Pain of Recent Onset: Assessment and Diagnosis. NICE clinical guideline no. 95. Royal College of Physicians; 2010.

Rouan GW, Lee TH, Cook EF, et al. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol. 1989;64(18):1087-1092.

Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes [published correction appears in JAMA . 2006;295(19):2250]. JAMA. 2005;294(20):2623-2629.

Bösner S, Becker A, Abu Hani M, et al. Accuracy of symptoms and signs for coronary heart disease assessed in primary care. Br J Gen Pract. 2010;60(575):e246-e257.

Bittencourt MS, Hulten E, Polonsky TS, et al. European Society of Cardiology—recommended coronary artery disease consortium pretest probability scores more accurately predict obstructive coronary disease and cardiovascular events than the Diamond and Forrester score: the Partners Registry [published correction appears in Circulation . 2018; 138(5):e80]. Circulation. 2016;134(3):201-211.

Amsterdam EA, Wenger NK, Brindis RG, et al.; ACC/AHA Task Force members. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation . 2014;130(25):e433–e434]. Circulation. 2014;130(25):e344-e426.

Harskamp RE, Laeven SC, Himmelreich JCI, et al. Chest pain in general practice: a systematic review of prediction rules. BMJ Open. 2019;9(2):e027081.

Haasenritter J, Bösner S, Vaucher P, et al. Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule. Br J Gen Pract. 2012;62(599):e415-e421.

Aerts M, Minalu G, Bösner S, et al.; International Working Group on Chest Pain in Primary Care (INTERCHEST). Pooled individual patient data from five countries were used to derive a clinical prediction rule for coronary artery disease in primary care. J Clin Epidemiol. 2017;81:120-128.

Sox HC, Aerts M, Haasenritter J. Applying a clinical decision rule for CAD in primary care to select a diagnostic test and interpret the results [Point-of-Care Guide]. Am Fam Physician. 2019;99(9):584-586. Accessed September 15, 2020. https://www.aafp.org/afp/2019/0501/p584.html

Thygesen K, Alpert JS, Jaffe AS, et al.; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. Circulation. 2012;126(16):2020-2035.

Rude RE, Poole WK, Muller JE, et al. Electrocardiographic and clinical criteria for recognition of acute myocardial infarction based on analysis of 3,697 patients. Am J Cardiol. 1983;52(8):936-942.

Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) [published correction appears in J Am Coll Cardiol . 2006;48(8):1731]. J Am Coll Cardiol. 2002;40(8):1531-1540.

Metz LD, Beattie M, Hom R, et al. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis. J Am Coll Cardiol. 2007;49(2):227-237.

Newby DE, Adamson PD, Berry C, et al.; SCOT-HEART Investigators. Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med. 2018;379(10):924-933.

Yin X, Wang J, Zheng W, et al. Diagnostic performance of coronary computed tomography angiography versus exercise electrocardiography for coronary artery disease: a systematic review and meta-analysis. J Thorac Dis. 2016;8(7):1688-1696.

Nagel E, Greenwood JP, McCann GP, et al.; MR-INFORM Investigators. Magnetic resonance perfusion or fractional flow reserve in coronary disease. N Engl J Med. 2019;380(25):2418-2428.

Healthcare bluebook. Accessed May 7, 2020. https://www.healthcarebluebook.com/

Bösner S, Becker A, Abu Hani M, et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Fam Pract. 2010;27(4):363-369.

Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466-2469.

Zimmerman J. Validation of a brief inventory for diagnosis and monitoring of symptomatic gastro-oesophageal reflux. Scand J Gastroenterol. 2004;39(3):212-216.

Mousavi S, Tosi J, Eskandarian R, et al. Role of clinical presentation in diagnosing reflux-related non-cardiac chest pain. J Gastroenterol Hepatol. 2007;22(2):218-221.

Wang WH, Huang JQ, Zheng GF, et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis. Arch Intern Med. 2005;165(11):1222-1228.

Huffman JC, Pollack MH, Stern TA. Panic disorder and chest pain: mechanisms, morbidity, and management. Prim Care Companion J Clin Psychiatry. 2002;4(2):54-62.

Löwe B, Gräfe K, Zipfel S, et al. Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians' diagnosis. J Psychosom Res. 2003;55(6):515-519.

Imazio M, Gaita F, LeWinter M. Evaluation and treatment of pericarditis: a systematic review [published corrections appear in JAMA . 2016;315(1):90 and JAMA . 2015;314(18):1978]. JAMA. 2015;314(14):1498-1506.

Kaysin A, Viera AJ. Community-acquired pneumonia in adults: diagnosis and management [published correction appears in Am Fam Physician . 2017;95(7):414]. Am Fam Physician. 2016;94(9):698-706. Accessed September 15, 2020. https://www.aafp.org/afp/2016/1101/p698

Htun TP, Sun Y, Chua HL, et al. Clinical features for diagnosis of pneumonia among adults in primary care setting: a systematic and meta-review. Sci Rep. 2019;9(1):7600.

Marchello CS, Ebell MH, Dale AP, et al. Signs and symptoms that rule out community-acquired pneumonia in outpatient adults: a systematic review and meta-analysis. J Am Board Fam Med. 2019;32(2):234-247.

Cao AMY, Choy JP, Mohanakrishnan LN, et al. Chest radiographs for acute lower respiratory tract infections. Cochrane Database Syst Rev. 2013(12):CD009119.

Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure?. JAMA. 2005;294(15):1944-1956.

Ebell MH. Diagnosis of heart failure with reduced ejection fraction [Point-of-Care Guide]. Am Fam Physician. 2020;101(4):230-232. Accessed April 8, 2020. https://www.aafp.org/afp/2020/0215/p230.html

Roalfe AK, Mant J, Doust JA, et al. Development and initial validation of a simple clinical decision tool to predict the presence of heart failure in primary care: the MICE (male, infarction, crepitations, edema) rule. Eur J Heart Fail. 2012;14(9):1000-1008.

West J, Goodacre S, Sampson F. The value of clinical features in the diagnosis of acute pulmonary embolism: systematic review and meta-analysis. QJM. 2007;100(12):763-769.

Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98-107.

Singh B, Parsaik AK, Agarwal D, et al. Diagnostic accuracy of pulmonary embolism rule-out criteria: a systematic review and meta-analysis. Ann Emerg Med. 2012;59(6):517-520.e1–4.

Kline JA, Webb WB, Jones AE, et al. Impact of a rapid rule-out protocol for pulmonary embolism on the rate of screening, missed cases, and pulmonary vascular imaging in an urban US emergency department. Ann Emerg Med. 2004;44(5):490-502.

Klompas M. Does this patient have an acute thoracic aortic dissection?. JAMA. 2002;287(17):2262-2272.

Ohle R, Kareemi HK, Wells G, et al. Clinical examination for acute aortic dissection: a systematic review and meta-analysis. Acad Emerg Med. 2018;25(4):397-412.

McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87(3):177-182. Accessed September 15, 2020. https://www.aafp.org/afp/2013/0201/p177.html

Cayley WE. Diagnosing the cause of chest pain. Am Fam Physician. 2005;72(10):2012-2021. Accessed September 18, 2020. https://www.aafp.org/afp/2005/1115/p2012.html

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Characteristics of ambulatory care visits to family medicine specialists in Taiwan: a nationwide analysis

An-min lynn.

Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

Tzu-Chien Shih

Cheng-hao hung, ming-hwai lin, shinn-jang hwang, tzeng-ji chen, associated data.

The following information was supplied regarding the deposition of related data:

Raw data for this work was obtained by application from the National Health Insurance Research Database, Taiwan ( http://nhird.nhri.org.tw/en/index.htm ) and may not be shared according to the Database’s rules governing use. Access to the data used in this study may be obtained by citizens of the Republic of China who fulfill the requirements of conducting research projects.

Although family medicine (FM) is the most commonly practiced specialty among all the medical specialties, its practice patterns have seldom been analyzed. Looking at data from Taiwan’s National Health Insurance Research Database, the current study analyzed ambulatory visits to FM specialists nationwide. From a sample dataset that randomly sampled one out of every 500 cases among a total of 309,880,000 visits in 2012, it was found that 18.8% ( n = 116, 551) of the 619,760 visits in the dataset were made to FM specialists. Most of the FM services were performed by male FM physicians. Elderly patients above 80 years of age accounted for only 7.1% of FM visits. The most frequent diagnoses (22.8%) were associated acute upper respiratory infections (including ICD 460, 465 and 466). Anti-histamine agents were prescribed in 25.6% of FM visits. Hypertension, diabetes and dyslipidemia were the causes of 20.7% of the ambulatory visits made to FM specialists of all types, while those conditions accounted for only 10.6% of visits to FM clinics. The study demonstrated the relatively low proportion of chronic diseases that was managed in FM clinics in Taiwan, and our detailed results could contribute to evidence-based discussions on healthcare policymaking and residency training.

Introduction

Family medicine (FM) specialists act as general practitioners and provide primary care services in the community, including solving minor cases, making referrals for major diseases, and providing and promoting preventive health services. Because of an overemphasis on medical specialization over the past several decades, the importance of FM specialists has been increasingly noticed in terms of the benefits they provide to patients ( Ryan et al., 2001 ; Shi et al., 2003 ; Baicker & Chandra, 2004 ; Cooper, 2009a ; Cooper, 2009b ; Baicker & Chandra, 2009 ). The associated issues, such as the practicing environments of FM specialists and primary care reforms, also affect the government’s finances and public health ( Bindman & Majeed, 2003 ; Van Weel & Del Mar, 2004 ; Chou et al., 2007 ; Skinner et al., 2009 ; Chang et al., 2011 ; Katz et al., 2012 ). On the other hand, the aging societies and inequalities in health care have increased the complexity of constructing deliberate health policies ( Beckman & Anell, 2013 ; Jin, 2014 ). Comprehensive information about family medicine care is essential to the analysis of existing problems. In the United States, the Primary Care Network Survey and National Ambulatory Medical Care Survey (NAMCS) have been useful in this regard in terms of indicating the number of ambulatory visits to primary care clinics and delineating the national profile of primary care ( Cypress, 1982 ; Cypress, 1983a ; Cypress, 1983b ; Cantrell, Young & Martin, 2002 ; Binns et al., 2007 ). Information from Canadian physicians has also proved valuable in this regard ( Cunningham et al., 2014 ). Other countries have also reported on the working status of practicing FMS ( Okkes et al., 2002 ; Emmanuel, Phua & Cheong, 2004 ; Aboulghate et al., 2013 ; Raza et al., 2014 ; Granja, Ponte & Cavadas, 2014 ). Nevertheless, literature looking at the practice of FM on a nationwide basis remains sparse in most countries, including Taiwan.

The purpose of the current study was to explore the nationwide characteristics of ambulatory visits to FM clinics recorded by Taiwan’s National Health Insurance (NHI) system in 2012. We analyzed the ages and genders of the patients and physicians, the procedures conducted, diagnoses made, and medications prescribed during these visits. The findings may offer valuable information for future discussions on healthcare policy making and FM residency training programs, and may also provide a foundation for making international comparisons.

Materials & Methods

The NHI program in Taiwan, which started in 1995, provides comprehensive healthcare coverage to more than 99% of the country’s residents. The National Health Insurance Administration of the Ministry of Health and Welfare has released all de-identified claims data dating back to 1999 for academic research in the form of the National Health Insurance Research Database (NHIRD; http://w3.nhri.org.tw/nhird/ ). The conduct of the study had been approved by the institutional review board (IRB) of Taipei Veterans General Hospital, Taipei, Taiwan (2013-04-005E). Because of anonymized data that are publicly available on application, our study is exempt from full IRB review.

Study population

We performed a descriptive and cross-sectional study by accessing the sampling files for the year 2012 (S_CD20120.DAT and S_OO20120.DAT of NHIRD). In the terminology of NHIRD, the dataset “CD” is defined as the collection of all outpatient visit files, while the “OO” dataset comprises the outpatient order files. According to NHIRD, the size of subset from each month is determined by the ratio of the amount of data to that of the entire year. Then the systemic sampling is performed for each month to randomly choose a representative subset. A sampling database is obtained by combining the subsets from 12 months. The sampling database of S_CD20120 was constructed at first, and then the relative observations in S_OO20120 were drawn out accordingly. These two sampling files, which exclude information on visits to dental clinics and traditional Chinese medicine clinics, contain a total of 619,760 medical records, and were obtained by a 0.2% sampling ratio from the CD and OO datasets for 2012. Each individual record included the patient’s identification number, birth date, gender, medical facility, date of visit, the specialty of the consulting physician, and up to three diagnosis codes as defined by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).

From the sampling data, the details of 116,551 ambulatory visits to FM specialists were extracted and analyzed. A list of reimbursable drugs with additional coding in the Anatomical Therapeutic Chemical (ATC) classification system ( http://www.whocc.no/atc_ddd_index/ ) was provided by the National Health Insurance Administration. The basic data of the contracted medical care institutions presented the status of accreditation: academic medical center, metropolitan hospital, local community hospital, or physician clinic. We also analyzed the diagnoses made, procedures conducted, and medications prescribed during the visits to facilities of various levels.

Statistical analysis

The programming software Perl version 5.20.2 (produced by Perl) was used for data processing, and regular descriptive statistics were displayed.

Based on the sampling data, of the 619,760 ambulatory visits made in 2012, 18.8% ( n = 116, 551) were made to FM specialists—making FM the most commonly utilized specialty among all physician specialties ( Table 1 ). FM also accounted for 8.3% of insurance claims, with those claims amounting to an estimated NT$309 billion in 2012.

Among the ambulatory visits to FM specialists, 53.1% were made by female patients ( n = 61,974) and 46.9% were made by male patients ( n = 54,577). Stratifying the records by age group demonstrated that patients aged 50–59 years had the highest proportion of ambulatory visits to FM specialists among both genders (male: 18.0%, n = 9,855; female: 19.2%, n = 11,955), followed by patients aged 60–69 years among both genders (male: 15.3%, n = 8,360; female: 16.5%, n = 10, 641) in Fig. 1 . No remarkable gap in the number of visits was evident between the various age groups, except that the number of visits by patients aged 80–89 years and 90–99 years dropped obviously from the numbers of visits made by all the other younger groups.

The number of ambulatory visits to FM specialists in terms of the physicians’ gender and age is presented in Fig. 2 . These data indicated that there are far fewer female physicians than male physicians in all the age ranges. Compared with the other working-age age ranges, the number of female physicians was the highest in the 30–39 years ( n = 3,806) range, although the number of female physicians in that range was still below the number of male physicians in that age range.

In the current investigation, FM clinics remained the major ambulatory care providers, handling 89.9% ( n = 104,796) of the ambulatory visits to FM, followed by metropolitan hospitals (4.1%), local community hospitals (3.7%), and academic medical centers (2.3%). Among the ambulatory visits to FM specialists, 65.5% ( n = 76,392) produced only one diagnosis. The top 10 most common diagnosis groups (based on the first diagnosis code in every medical record) are listed in Table 2 . The top diagnosis was acute upper respiratory infection (13.1%), followed by essential hypertension (9.9%), general symptoms (6.9%), acute bronchitis and bronchiolitis (5.9%), and diabetes mellitus (5.7%). The ranking of the diagnosis groups varied according to hospital level.

In general, the most common procedures performed during ambulatory visits to FM were checks of glucose (3.7%, n = 4,269), cholesterol, (2.3%, n = 2,719), triglyceride (2.2%, n = 2,599), S-GPT/ALT (1.9%, n = 2,270), serum creatinine (7.8%, n = 2,802), and HbA1c (1.5%, n = 1,781) levels. The application of the procedures had high consistency between the ambulatory care settings ( Table 3 ).

Of the ambulatory visits to FM specialists, 89.4% ( n = 104,171) included the prescribing of medication. Approximately 55.8% of the visits where medication was prescribed recorded prescriptions of three or more drugs (one drug 15.8%, two drugs 17.8%, three drugs 19.6%, four drugs 16.9%, five drugs 10.4%, six drugs 5.0%, seven or more drugs 3.9%). The most commonly prescribed medications were anti-histamines for systemic use (25.6%), non-steroid anti-inflammatory and anti-rheumatic products (24.6%), and other analgesics and anti-pyretics (24.5%) ( Table 4 ).

In this report, FM clinics remained the primary ambulatory care providers, receiving 89.9% ( n = 104,796) of the ambulatory visits to FM clinics. This finding reveals that primary medical facilities are responsible for most of the FM specialists’ workloads. Indeed, all of the top 10 diseases can be managed by FM clinics. In other words, the character of ambulatory visits meets the expectation of primary medical care for minor conditions. However, the number of visits from patients aged over 80 years has markedly decreased. To our knowledge, multiple comorbidity and polypharmacy are prominent in this age group, and both conditions are prevalent in Taiwan ( Lai et al., 1995 ; Chan, Hao & Wu, 2009 ; Lin, Wang & Bai, 2011 ). These issues may have contributed to many patients in this age group being too weak to visit FM clinics and being transferred to other departments after being admitted for severe illnesses or comorbidities. In Taiwan, any transfer to a lower class accommodation is not popular. Therefore, patients aged over 80 years make fewer visits to FM clinics but make more visits to other types of specialists in hospitals instead. This suggests that developing and implementing a referral system policy for home medicine is vital.

We found among patients aged 30–79 years, women paid more visits to FM specialists than men. Some studies of health seeking behaviors revealed that female patients were more interested in health-related information and paid more attention to their own life, including ambulatory visits ( Ek, 2013 ; Galdas, Cheater & Marshall, 2005 ; Oliver et al., 2005 ). On the other hand, among patients aged 0–29 years in our study, males had more visits. It was unclear whether younger male patients had more risky behaviors or were more susceptible to fall ill. Besides, parents might decide the seeking health behaviors of children ( Chen et al., 2012 ) and boys usually receive more attention than girls.

In addition, the number of visits to FM clinics regarding chronic diseases such as hypertension (ICD 401), diabetes mellitus (250) and dyslipidemia (272) was less than half the number of such visits to other facilities. This suggests that patients prefer to receive regular medical treatment for chronic diseases in hospitals rather than in FM clinics, and that clinic physicians may not pay particular attention to chronic diseases, possibly due to benefit payments, the large number of waiting patients at the clinic, or a lack of the concept of holistic care. In the NHI program, no matter how much time a physician spends with a patient, the physician receives the same reimbursement. Therefore, doctors generally appear not to do much health counseling or education to identify potential patients with chronic diseases ( American Institute in Taiwan ). The government bodies have to innovate the methods of claims to encourage physicians to pay attention holistically ( Michael, 2006 ) so that preventive care can be provided. It is also necessary to educate members of the public so that they understand that the diagnosis and treatment of these diseases can be handled by FM clinics. Surely, since the highest number of patients visiting FM clinics consists of those aged 50–59 years, continuing medical education, with appropriate approaches and referrals, also needs to be ensured.

In our study, female physicians accounted for a small amount of visits to FM clinics. The gender disparity increased with age ( Fig. 2 ). The reason might be that fewer women became physicians in the past ( Taiwan Medical Association, 2015 ). Another finding was that the majority of visits were made to FM specialists aged 50–59 years. That is, the FM workforce in Taiwan was aging, a phenomenon also observed in obstetrician-gynecologists ( Lynn et al., 2015 ).

Resident doctors may have abundant training in academic areas, but they should also have clear insights regarding real-world experiences and, maybe, related lessons. FM specialists should not only manage upper respiratory infections but should also manage geriatric conditions, demonstrate healthy behaviors, including good diets and exercise, and adequately perform health counseling in their future practice. This may encourage medical students to consider all the facts in choosing a career or calling, rather than working exclusively with the common cold.

As for the subject of medication, anti-histamine agents are prescribed most often. Since the NHI program has limited the use of antibiotics for URI or common colds since 2001, antibiotics did not show up among the top 10 most prescribed medications. Symptomatic agents including NSAIDs, antipyretics, expectorants, and cough suppressants were all used for URI. However, antacids are still prescribed often (12.5%), even though the percentage of gastritis diagnoses (3.5%) was not as high as the medication usage. This is because many patients believe they need antacid to protect their stomachs from medication damage ( Chen, Chou & Hwang, 2003 ). To decrease the related expenses and potential drug-drug interactions, it is important to educate both the public and physicians that overuse of antacids is not good for the body and that real GI discomfort needs to be diagnosed and treated separately.

The medical care expenses claimed by FM specialists accounted for 8.3% of the total ambulatory costs ( Table 1 ). On average, one ambulatory visit at FM cost less than at most specialties. It might be attributed to fewer laboratory examinations at FM visits. Similar low cost per visit was also observed at visits to otorhinolaryngologists. URI, the most frequent disease seen at both specialties, might play a role ( Liao et al., 2011 ).

The resources used in this study, which were compiled by the National Health Insurance Administration, have imposed limitations on our analysis. For instance, the results do not include self-pay procedures or medicines, such as expensive vaccines and cosmetic medicines. However, since the NHI program covers most diseases and requirements for preventive care, the above issues did not have a significant impact on the characteristics of ambulatory visits recorded in this study, although it should also be noted that our figures do not present a complete picture.

Conclusions

In Taiwan, FM is the most common utilized specialty of ambulatory care visits and acute URI is the most common diagnosis seen. The decreasing frequency of visits to FM by patients aged above 80 years is notable. The diseases managed differed between hospitals and FM clinics, especially with regard to chronic diseases. In addition, the high proportion of antacids prescribed during visits requires further study.

Funding Statement

The data used in this study came from the NHIRD provided by the National Health Insurance Administration, Ministry of Health and Welfare, and managed by the National Health Research Institutes in Taiwan. The interpretation and conclusions contained herein do not indicate those of the National Health Insurance Administration, Ministry of Health and Welfare, or the National Health Research Institutes. This study was supported by grants from the National Science Council (NSC 100-2410-H-010-001-MY3) and Taipei Veterans General Hospital (V104E10-001). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Additional Information and Declarations

The authors declare that there are no competing interests.

An-Min Lynn conceived and designed the experiments, contributed reagents/materials/analysis tools, wrote the paper, prepared figures and/or tables.

Tzu-Chien Shih and Cheng-Hao Hung conceived and designed the experiments.

Ming-Hwai Lin analyzed the data, contributed reagents/materials/analysis tools, reviewed drafts of the paper.

Shinn-Jang Hwang analyzed the data.

Tzeng-Ji Chen analyzed the data, reviewed drafts of the paper.

Term: Continuity Of Care (COC) (Ambulatory)

Glossary definition.

Last Updated : 2020-02-24 Last Reviewed : 2009-02-12 -->

Definition:

• A provider may be defined either as an individual physician, a physician group practice, primary caregiver or a clinic. This definition includes general practitioners (GP)/ family physicians (FP), (now referred to as family physicians), nurse practitioners, and may also include specialist physicians (SP) depending on the focus of the research project.
• In several MCHP research projects, the term "Continuity of Care" is used to describe what is now called Majority of Care (Ambulatory).

Related concepts  

• Health Indicators: Indicators of Health Status and Healthcare Use
• Measuring Continuity of Care (Continuity of Care Index)
• Measuring Majority of Care
• Patient Allocation Algorithm: Assigning Patients to Physicians, Physician Groups or Clinics
• Regular Source of Care (RSOC)

Related terms  

• Ambulatory Visits - Physician
• Continuity of Care Index (COCI)
• Family Physician (FP) / Family Physicians
• General Practitioner (GP) / Family Practitioner (FP)
• Majority of Care (Ambulatory)
• Patient Allocation
• Patient Characteristics
• Physician Practice Characteristics
• Primary Care Providers
• Proportion of Visits to Usual Provider (Continuity of Care)
• Quality of Care
• Specialist Physicians (SP)

References  

• Katz A, De Coster C, Bogdanovic B, Soodeen R, Chateau D. Using Administrative Data to Develop Indicators of Quality in Family Practice . Winnipeg, MB: Manitoba Centre for Health Policy, 2004. [ Report ] [ Summary ] ( View )

Term used in  

• Brownell M, Chartier M, Au W, Schultz J. Evaluation of the Healthy Baby Program . Winnipeg, MB: Manitoba Centre for Health Policy, 2010. [ Report ] [ Summary ] ( View )
• Brownell M, De Coster C, Penfold R, Derksen S, Au W, Schultz J, Dahl M. Manitoba Child Health Atlas Update . Winnipeg, MB: Manitoba Centre for Health Policy, 2008. [ Report ] [ Summary ] [ Additional Materials ] ( View )
• Brownell M, Santos R, Kozyrskyj A, Roos N, Au W, Dik N, Chartier M, Girard D, Ekuma O, Sirski M, Tonn N, Schultz J. Next Steps in the Provincial Evaluation of the BabyFirst Program: Measuring Early Impacts on Outcomes Associated with Child Maltreatment . Winnipeg, MB: Manitoba Centre for Health Policy, 2007. [ Report ] [ Summary ] ( View )
• Chartier M, Finlayson G, Prior H, McGowan K, Chen H, de Rocquigny J, Walld R, Gousseau M. Health and Healthcare Utilization of Francophones in Manitoba . Winnipeg, MB: Manitoba Centre for Health Policy, 2012. [ Report ] [ Summary ] ( View )
• Cree M, Roos NP, Yang Q, Carriere KC. Hypertension patients and their general practitioners. Healthcare Manage Forum 2001;14(2):33-40.( View )
• Fransoo R, Martens P, Burland E, The Need to Know Team, Prior H, Burchill C. Manitoba RHA Indicators Atlas 2009 . Winnipeg, MB: Manitoba Centre for Health Policy, 2009. [ Report ] [ Summary ] [ Additional Materials ] ( View )
• Fransoo R, Martens P, The Need to Know Team, Burland E, Prior H, Burchill C, Chateau D, Walld R. Sex Differences in Health Status, Health Care Use, and Quality of Care: A Population-Based Analysis for Manitoba's Regional Health Authorities . Winnipeg, MB: Manitoba Centre for Health Policy, 2005. [ Report ] [ Summary ] [ Additional Materials ] ( View )
• Frohlich N, Katz A, De Coster C, Dik N, Soodeen RA, Watson D, Bogdanovic B. Profiling Primary Care Physician Practice in Manitoba . Winnipeg, MB: Manitoba Centre for Health Policy, 2006. [ Report ] [ Summary ] ( View )
• Hilderman T, Katz A, Derksen S, McGowan K, Chateau D, Kurbis C, Allison S, Reimer JN. Manitoba Immunization Study . Winnipeg, MB: Manitoba Centre for Health Policy, 2011. [ Report ] [ Summary ] ( View )
• Himelhoch S, Weller WE, Wu AW, Anderson GF, Cooper LA. Chronic medical illness, depression, and use of acute medical services among Medicare beneficiaries. Med Care 2004;42(6):512-521. [ Abstract ] ( View )
• Katz A, Chateau D, Bogdanovic B, Taylor C, McGowan K-L, Rajotte L, Dziadek J. Physician Integrated Network: A Second Look . Winnipeg, MB: Manitoba Centre for Health Policy, 2014. [ Report ] [ Summary ] [ Updates and Errata ] ( View )
• Katz A, Martens P, Chateau D, Bogdanovic B, Koseva I, McDougall C, Boriskewich E. Understanding the Health System Use of Ambulatory Care Patients . Winnipeg, MB: Manitoba Centre for Health Policy, 2013. [ Report ] [ Summary ] ( View )
• Liem JJ, Kozyrskyj AL, Huq S, Becker AB. The risk of developing food allergy in premature or low-birth-weight children. J Allergy Clin Immunol 2007;119(5):1203-1209. [ Abstract ] ( View )
• Martens P, Brownell M, Au W, MacWiliam L, Prior H, Schultz J, Guenette W, Elliott L, Buchan S, Anderson M, Caetano P, Metge C, Santos R, Serwonka K. Health Inequities in Manitoba: Is the Socioeconomic Gap in Health Widening or Narrowing Over Time? Winnipeg, MB: Manitoba Centre for Health Policy, 2010. [ Report ] [ Summary ] [ Updates and Errata ] [ Additional Materials ] ( View )
• Martens P, Fransoo R, The Need to Know Team, Burland E, Prior H, Burchill C, Romphf L, Chateau D, Bailly A, Ouelette C. What Works? A First Look at Evaluating Manitoba's Regional Health Programs and Policies at the Population Level . Winnipeg, MB: Manitoba Centre for Health Policy, 2008. [ Report ] [ Summary ] [ Additional Materials ] ( View )
• Martens PJ, Bartlett J, Burland E, Prior H, Burchill C, Huq S, Romphf L, Sanguins J, Carter S, Bailly A. Profile of Metis Health Status and Healthcare Utilization in Manitoba: A Population-Based Study . Winnipeg, MB: Manitoba Centre for Health Policy, 2010. [ Report ] [ Summary ] [ Updates and Errata ] [ Additional Materials ] ( View )
• Menec V, Sirski M, Attawar D. Does continuity of care matter in a universally insured population? Health Serv Res 2005;40:389-400. [ Abstract ] ( View )
• Menec VH, Roos NP, Black C, Bogdanovic B. Characteristics of patients with a regular source of care. Can J Public Health 2001;92(4):299-303. [ Abstract ] ( View )
• Mustard CA, Mayer T, Black C, Postl B. Continuity of pediatric ambulatory care in a universally insured population. Pediatrics 1996;98(6 Pt 1):1028-1034. [ Abstract ] ( View )
• Roos NP, Fransoo R, Bogdanovic B, Friesen D, Frohlich N, Carriere KC, Patton D, Wall R. Needs-Based Planning for Manitoba's Generalist Physicians . Winnipeg, MB: Manitoba Centre for Health Policy and Evaluation, 1996. [ Report ] [ Summary ] ( View )
• Shapiro E. Manitoba Health Care Studies and their Policy Implications (Report #91-04-01) . Winnipeg, MB: Manitoba Centre for Health Policy and Evaluation, 1991. [ Report ] ( View )

Emergency department or emergency room visit

Several approaches to defining emergency department or emergency room visits are used in Health, United States .

National Health Interview Survey (NHIS)

Starting with the 1997 NHIS, respondents to the Sample Adult questionnaire, Sample Child questionnaire (a knowledgeable adult, usually a parent), and Family Core questionnaire are asked about the number of visits to hospital emergency rooms during the past 12 months, including visits that resulted in hospitalization. Respondents are asked, “During the past 12 months, how many times have [you/person/child] gone to a hospital emergency room about [your/his/her] health? (This includes emergency room visits that resulted in a hospital admission.)”

National Hospital Ambulatory Medical Care Survey

A hospital emergency department visit is a direct personal exchange between a patient and either a physician or a health care provider working under the physician’s supervision, for the purpose of seeking care and receiving personal health services. (Also see Sources and Definitions, Emergency department ; Injury-related visit .)

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