Attending the TOC clinic was investigated as a predictor of hospital readmission within 30 days. Rates of readmission-free survival were evaluated by the Kaplan-Meier method. Demographic and clinical variables were included as explanatory variables in a Cox proportional-hazards regression analysis. The study population included hospital discharges with an average patient age of 62 years. The majority of the patients in this sample were female Average length of hospital stay was 4.
In this sample, 40 patients Patients who were readmitted to the hospital within 30 days of discharge had a higher number of hospital admissions in the last year 1. The rate of readmission-free survival differed between patients who attended the TOC clinic and those who did not 3. This relationship was explored with Cox regression, which indicated that attending the TOC was a significant negative predictor of hospital readmission hazard ratio 0.
The risk of readmission was higher in patients admitted with DKA hazard ration No other factors were significantly emerged as predictors for hospital readmission Table 2. Cox proportional-hazards regression analysis of risk factors for hospital readmission. A Kaplan-Meier plot comparing the readmission-free survival of patients who did or did not attend the TOC is shown in Figure 1. Kaplan-Meier plot comparing day readmission rates between patients who did or did not attend the transition of care clinic.
This study indicates that the utilization of a transition of care clinic after discharge had a potential positive outcome in reducing the readmission rates 30 days after discharge. The reduction of rehospitalization rate observed in our study, from This reduction, which was statistically adjusted, is not explained by any other factors studied in the target population. It also indicates that this system, which serves the rural area of southern Illinois, is a peculiar health care system.
There are several factors that may have contributed to this reduction, including that early access to medical care helped facilitate patient education and assured the patients' understanding of their complex medical issues; the guarantee of medication reconciliation and access to new prescription upon follow-up; the strengthening of the doctor-patient relationship, especially after the hospital encounter with a strange provider the hospitalist ; reduction of loss of follow-up by providing early appointments; and providing an earlier opportunity to reassess the patient for change in health status.
This intervention goes in line with multiple efforts by hospital administrators and governmental agencies to reduce rehospitalization by proving a high-value care [ 5 ]. There is not strong evidence that a single intervention is enough to significantly reduce readmission rates [ 9 ], so more complex interventions are required in order to effectively achieve this goal [ 26 ].
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The heterogeneity of the results found in literature could be a good reflection of the complexity of our healthcare system as well as the dynamic interaction with our complex medical patients. The system of profound knowledge, proposed by the quality improvement pioneer Dr.
Edwards Deming, supports this assumption. As stated in Deming's book, there are four parts of a system that need to be understood in order to obtain meaningful improvement: appreciation of the system, understanding variation, obtaining a theory of knowledge, and taking psychology into consideration [ 27 ]. Our study corroborates previously reported outcomes that timely outpatient visits after discharge, arranged through a transition of care model, reduce readmission rates [ 11 , 16 , 20 , 28 ].
Other studies have shown improved rates of readmission among only high risk populations [ 13 , 21 ] or have demonstrated no clear benefit from the same intervention [ 19 , 22 ]. These results have been analyzed by Hansen et al. Our patient population displays a high CCI that indicates a potentially higher risk of rehospitalization, which may partially explain the observed benefit from using a transition of care model in our institution.
Multiple interventions designed to reduce rehospitalization rates have been previously described. Postdischarge calls are one of the most common interventions that have been widely adopted [ 9 , 26 ]. The effectiveness of such intervention varies in the literature, again reflecting the complexity of the factors contributing to the rehospitalization process. In our study, the observed effect cannot be assumed to be due to the follow-up calls as all patients, whether they attended the clinic or not, received calls.
However, the additive effect of said calls may have contributed to the reduction of the readmission rate. Therefore, we posit that the integration of hospital and outpatient care is key to reducing readmissions. Our hospital's integrated health system contributes to lower admissions and thereby avoids readmissions, through its emphasis on primary and preventive care, community-based education, and enhanced communication and flow of information through easily accessible electronic health records among inpatient and outpatient providers.
Our study has multiple limitations. First, the allocation of patients was not randomized due to lack of appropriate volume of patients and resources. Second, the hospital readmission rate was calculated for a single institution. As patients could have received care from other hospitals in the region, this may not reflect the actual rehospitalization rate. Third, the trial was not blinded, although that is unlikely to affect the results because the outcome measures were objective and extracted from the healthcare records database.
Fourth, while our study cannot be safely generalized and applied to other settings, it indicates that a better understanding of current local healthcare systems, identification of local patient characteristics and medical needs, and the proper allocation of resources in the community could help structure appropriate interventions to decrease rehospitalization rates. Fifth, the patients who attend the TOC clinic are the same patients who are likely to be more compliant in their postdischarge care, which also could have a beneficial impact on the readmission risk.
Finally, our study was retrospective and observational in nature and thus we cannot assume a causal relationship. A smooth transition from the inpatient to the outpatient world constitutes a favorable model of care. Our study demonstrates that adopting a transition of care clinic reduced the readmission rates of our peculiar population.
Further studies are warranted to assess the patient population characteristics that benefit from a transition of care clinic model as a method to reduce rehospitalization. They also would like to thank Lydia Howes for her efforts in editing the language of the manuscript. National Center for Biotechnology Information , U. Journal List Adv Med v. Adv Med.
Published online Aug 2. Author information Article notes Copyright and License information Disclaimer. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background Rehospitalization for medical patients is common. Objective To study the effect of a transition of care clinic model on the day rehospitalization rate in a single medical center.
Methods Retrospective observational analysis of adult patients discharged home from Memorial Medical Center from September 1, , through December 31, Results The study population included patient discharges.
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Conclusion Adopting a TOC model after discharging medical patients has reduced the readmission rates in our study. Introduction Providing high quality care for patients remains the ultimate goal for all health care providers. Materials and Methods Institutional review board review for this study was obtained from the Springfield Committee for Research Involving Human Subjects, who determined that it does not meet the criteria for research involving human subjects according to 45 CFR Study Design This study retrospectively analyzed all patients discharged from the Southern Illinois University general internal medicine teaching service from Memorial Medical Center September 1, to December 31, Statistical Analysis Attending the TOC clinic was investigated as a predictor of hospital readmission within 30 days.
Results The study population included hospital discharges with an average patient age of 62 years. Table 1 Patient characteristics. This issue, edited by Dr. Allen Repp, includes the following articles: Pericarditis; Bedside ultrasound evaluation of shock; Cardiac implantable device infections; Hypernatremia; Ischemic colitis; Guillain-Barre syndrome; Interpretation of thyroid function tests in the hospitalized patient; Terminal extubation; Parotitis; Preventing catheter-associated urinary tract infections; Hepatitis C in Hospital Medicine; and Literature Update in Hospital Medicine.
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George I. Kenneth Azarow. Hugh D. Thomas Ciesielski. Nelson L. Textbook of Interventional Neurology. Adnan I. Pediatric Cardiovascular Medicine. James H. Oxford Handbook of Rheumatology. Most tribal societies provide no guarantee of healthcare for the population as a whole. In such societies, healthcare is available to those that can afford to pay for it or have self-insured it either directly or as part of an employment contract or who may be covered by care financed by the government or tribe directly.
Transparency of information is another factor defining a delivery system. While the US healthcare system has come under fire for lack of openness,  new legislation may encourage greater openness. There is a perceived tension between the need for transparency on the one hand and such issues as patient confidentiality and the possible exploitation of information for commercial gain on the other.
Primary care medical services are provided by physicians , physician assistants , nurse practitioners , or other health professionals who have first contact with a patient seeking medical treatment or care.
These occur in physician offices, clinics , nursing homes , schools, home visits, and other places close to patients. These include treatment of acute and chronic illnesses, preventive care and health education for all ages and both sexes. Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made for those patients who required the expertise or procedures performed by specialists.
These include both ambulatory care and inpatient services, Emergency departments , intensive care medicine , surgery services, physical therapy , labor and delivery , endoscopy units, diagnostic laboratory and medical imaging services, hospice centers, etc. Some primary care providers may also take care of hospitalized patients and deliver babies in a secondary care setting. Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic and treatment facilities not generally available at local hospitals.
These include trauma centers , burn treatment centers, advanced neonatology unit services, organ transplants , high-risk pregnancy, radiation oncology , etc. Modern medical care also depends on information — still delivered in many health care settings on paper records, but increasingly nowadays by electronic means. In low-income countries, modern healthcare is often too expensive for the average person.
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International healthcare policy researchers have advocated that "user fees" be removed in these areas to ensure access, although even after removal, significant costs and barriers remain. Separation of prescribing and dispensing is a practice in medicine and pharmacy in which the physician who provides a medical prescription is independent from the pharmacist who provides the prescription drug.
In the Western world there are centuries of tradition for separating pharmacists from physicians. In Asian countries it is traditional for physicians to also provide drugs. Working together as an interdisciplinary team , many highly trained health professionals besides medical practitioners are involved in the delivery of modern health care. Examples include: nurses , emergency medical technicians and paramedics, laboratory scientists, pharmacists , podiatrists , physiotherapists , respiratory therapists , speech therapists , occupational therapists , radiographers, dietitians , and bioengineers , surgeons , surgeon's assistant , surgical technologist.
The scope and sciences underpinning human medicine overlap many other fields. Dentistry , while considered by some a separate discipline from medicine, is a medical field. A patient admitted to the hospital is usually under the care of a specific team based on their main presenting problem, e. Physicians have many specializations and subspecializations into certain branches of medicine, which are listed below.
There are variations from country to country regarding which specialties certain subspecialties are in.
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In the broadest meaning of "medicine", there are many different specialties. In the UK, most specialities have their own body or college, which have its own entrance examination. These are collectively known as the Royal Colleges, although not all currently use the term "Royal". The development of a speciality is often driven by new technology such as the development of effective anaesthetics or ways of working such as emergency departments ; the new specialty leads to the formation of a unifying body of doctors and the prestige of administering their own examination.
Within medical circles, specialities usually fit into one of two broad categories: "Medicine" and "Surgery. At present, some specialties of medicine do not fit easily into either of these categories, such as radiology, pathology, or anesthesia. Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate or treat a pathological condition such as disease or injury , to help improve bodily function or appearance or to repair unwanted ruptured areas for example, a perforated ear drum.
Surgeons must also manage pre-operative, post-operative, and potential surgical candidates on the hospital wards.
Surgery has many sub-specialties, including general surgery , ophthalmic surgery , cardiovascular surgery , colorectal surgery , neurosurgery , oral and maxillofacial surgery , oncologic surgery , orthopedic surgery , otolaryngology , plastic surgery , podiatric surgery , transplant surgery , trauma surgery , urology , vascular surgery , and pediatric surgery. In some centers, anesthesiology is part of the division of surgery for historical and logistical reasons , although it is not a surgical discipline. Other medical specialties may employ surgical procedures, such as ophthalmology and dermatology , but are not considered surgical sub-specialties per se.
Surgical training in the U. Sub-specialties of surgery often require seven or more years. In addition, fellowships can last an additional one to three years. Because post-residency fellowships can be competitive, many trainees devote two additional years to research. Thus in some cases surgical training will not finish until more than a decade after medical school. Furthermore, surgical training can be very difficult and time-consuming. Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases.
According to some sources, an emphasis on internal structures is implied. Because their patients are often seriously ill or require complex investigations, internists do much of their work in hospitals. Formerly, many internists were not subspecialized; such general physicians would see any complex nonsurgical problem; this style of practice has become much less common. In modern urban practice, most internists are subspecialists: that is, they generally limit their medical practice to problems of one organ system or to one particular area of medical knowledge.
For example, gastroenterologists and nephrologists specialize respectively in diseases of the gut and the kidneys. In the Commonwealth of Nations and some other countries, specialist pediatricians and geriatricians are also described as specialist physicians or internists who have subspecialized by age of patient rather than by organ system.
Elsewhere, especially in North America, general pediatrics is often a form of primary care. There are many subspecialities or subdisciplines of internal medicine :. Training in internal medicine as opposed to surgical training , varies considerably across the world: see the articles on medical education and physician for more details.
In North America, it requires at least three years of residency training after medical school, which can then be followed by a one- to three-year fellowship in the subspecialties listed above. In general, resident work hours in medicine are less than those in surgery, averaging about 60 hours per week in the US. This difference does not apply in the UK where all doctors are now required by law to work less than 48 hours per week on average.
The following are some major medical specialties that do not directly fit into any of the above-mentioned groups:. Medical education and training varies around the world. It typically involves entry level education at a university medical school , followed by a period of supervised practice or internship , or residency. This can be followed by postgraduate vocational training. A variety of teaching methods have been employed in medical education, still itself a focus of active research.
Since knowledge, techniques, and medical technology continue to evolve at a rapid rate, many regulatory authorities require continuing medical education. Medical practitioners upgrade their knowledge in various ways, including medical journals , seminars, conferences, and online programs. In most countries, it is a legal requirement for a medical doctor to be licensed or registered. In general, this entails a medical degree from a university and accreditation by a medical board or an equivalent national organization, which may ask the applicant to pass exams.
This restricts the considerable legal authority of the medical profession to physicians that are trained and qualified by national standards. It is also intended as an assurance to patients and as a safeguard against charlatans that practice inadequate medicine for personal gain. While the laws generally require medical doctors to be trained in "evidence based", Western, or Hippocratic Medicine, they are not intended to discourage different paradigms of health. In the European Union, the profession of doctor of medicine is regulated. A profession is said to be regulated when access and exercise is subject to the possession of a specific professional qualification.
The regulated professions database contains a list of regulated professions for doctor of medicine in the EU member states, EEA countries and Switzerland. Doctors who are negligent or intentionally harmful in their care of patients can face charges of medical malpractice and be subject to civil, criminal, or professional sanctions.
Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine. As a scholarly discipline, medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociology. Six of the values that commonly apply to medical ethics discussions are:. Values such as these do not give answers as to how to handle a particular situation, but provide a useful framework for understanding conflicts. When moral values are in conflict, the result may be an ethical dilemma or crisis.
Sometimes, no good solution to a dilemma in medical ethics exists, and occasionally, the values of the medical community i. Conflicts can also arise between health care providers, or among family members. For example, some argue that the principles of autonomy and beneficence clash when patients refuse blood transfusions , considering them life-saving; and truth-telling was not emphasized to a large extent before the HIV era.
Prehistoric medicine incorporated plants herbalism , animal parts, and minerals. In many cases these materials were used ritually as magical substances by priests, shamans , or medicine men. Well-known spiritual systems include animism the notion of inanimate objects having spirits , spiritualism an appeal to gods or communion with ancestor spirits ; shamanism the vesting of an individual with mystic powers ; and divination magically obtaining the truth. The field of medical anthropology examines the ways in which culture and society are organized around or impacted by issues of health, health care and related issues.
Early records on medicine have been discovered from ancient Egyptian medicine , Babylonian Medicine , Ayurvedic medicine in the Indian subcontinent , classical Chinese medicine predecessor to the modern traditional Chinese medicine , and ancient Greek medicine and Roman medicine.
In China, archaeological evidence of medicine in Chinese dates back to the Bronze Age Shang Dynasty , based on seeds for herbalism and tools presumed to have been used for surgery. In India, the surgeon Sushruta described numerous surgical operations, including the earliest forms of plastic surgery. In Greece, the Greek physician Hippocrates , the "father of modern medicine",   laid the foundation for a rational approach to medicine.
Hippocrates introduced the Hippocratic Oath for physicians, which is still relevant and in use today, and was the first to categorize illnesses as acute , chronic , endemic and epidemic, and use terms such as, "exacerbation, relapse , resolution, crisis, paroxysm , peak, and convalescence ".
The Hebrew contribution to the development of modern medicine started in the Byzantine Era , with the physician Asaph the Jew. The concept of hospital as institution to offer medical care and possibility of a cure for the patients due to the ideals of Christian charity, rather than just merely a place to die, appeared in the Byzantine Empire.
Although the concept of uroscopy was known to Galen, he did not see the importance of using it to localize the disease. It was under the Byzantines with physicians such of Theophilus Protospatharius that they realized the potential in uroscopy to determine disease in a time when no microscope or stethoscope existed. That practice eventually spread to the rest of Europe.
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After CE, the Muslim world had the works of Hippocrates, Galen and Sushruta translated into Arabic , and Islamic physicians engaged in some significant medical research. Notable Islamic medical pioneers include the Persian polymath , Avicenna , who, along with Imhotep and Hippocrates, has also been called the "father of medicine". For example, he was the first to recognize the reaction of the eye's pupil to light. In Europe, Charlemagne decreed that a hospital should be attached to each cathedral and monastery and the historian Geoffrey Blainey likened the activities of the Catholic Church in health care during the Middle Ages to an early version of a welfare state: "It conducted hospitals for the old and orphanages for the young; hospices for the sick of all ages; places for the lepers; and hostels or inns where pilgrims could buy a cheap bed and meal".