Skip to main content
eScholarship
Open Access Publications from the University of California

Scholarly Works (37 results)

  • Thesis
  • Peer Reviewed
UC San Francisco Electronic Theses and Dissertations (1991)

    Cover page: Prostaglandin production by sympathetic postganglionic neurons and its regulation by noradrenaline
    • Article
    • Peer Reviewed
    UC San Francisco Previously Published Works (2004)
    Acute respiratory infections (ARIs) are the most common infections in humans, accounting for half of all acute conditions each year in the United States. Acute bronchitis episodes represent a significant portion of these illnesses. This article focuses on acute bronchitis in otherwise healthy individuals.
      Cover page: Management of acute bronchitis in healthy adults
      • Thesis
      • Peer Reviewed
      UC San Francisco Electronic Theses and Dissertations (2016)

      As innovations in healthcare delivery systems and electronic medical records (EMR) data capture develop, the methods employed to evaluate interventions disseminated to improve the quality and efficiency of patient care should evolve as well. Through my dissertation work I have explored methods and strategies to employ when developing a responsible healthcare quality improvement (QI) evaluation in three separate domains.

      The first chapter of my dissertation focuses on assessing the effect of an intervention to identify and manage sepsis through a retrospective cohort study at the University of California San Francisco (UCSF) Medical Center. The analysis revealed that the UCSF sepsis bundle was associated with a 31% decreased risk of in-hospital mortality across hospital units (adjusted incidence rate ratio 0.69, 95% Confidence Interval (CI) 0.53, 0.91) and the adjusted number needed to treat was 15 (CI 8,69). In the second chapter of my dissertation, I present a review of the causal inference framework in the setting of interrupted time-series analysis and apply it to the formation of an analysis plan for a multidisciplinary intervention implemented at UCSF Medical Center to decrease the use of packed red blood cell transfusions. The third chapter of this work focuses on developing a metric to measure timely access to ambulatory specialty care in a cohort of nearly 60,000 UCSF primary care patients. I explored associations between population-level weekly ambulatory specialty care access defined three ways and the rate of population-level weekly poor health outcomes. Based on unadjusted Poisson analysis, there were correlations identified between poor outcomes and timely access to care in some specialties and the results provide a springboard for future exploration of metric performance and adjustment.

      As a body of work, my dissertation illustrates the breadth of the field of healthcare QI, providing evidence to support the continued evolution of robust methods for evaluation of interventions that will improve the quality, safety, and value of healthcare delivered nationally and globally.

        Cover page: Evaluating Quality Improvement Interventions: Strengthening Causal Inference with Observational Data
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2015)

        Background

        Specialty care access is increasingly constrained due to increasing demand for specialty care. Although much attention has been placed on the initial referral decision, much less is known about follow-up visit patterns. We examined the patterns of follow-up visits for new patients to a university-based cardiology practice and identified independent predictors of follow-up visits.

        Methods

        This is a retrospective cohort study of new patient visits using electronic medical record data. The primary outcome was a follow-up visit.

        Results

        Substantial variation in practice patterns by provider persisted after accounting for patient and disease factors. Most follow-up care was concentrated in a small population of patients.

        Conclusion

        Specialty care follow-up visits may represent a significant opportunity for standardization and quality improvement, and further studies are warranted to understand follow-up visits in specialty care.

        Implications

        Better understanding of between-provider differences could identify ways to reduce unnecessary follow-up visits.

        Level of evidence

        Single-institution study.
          Cover page: Variation in Follow-Up Visit Practices Across Clinicians and Conditions
          • Article
          • Peer Reviewed
          Poor and non-white patients are disproportionately infected with the hepatitis C virus (HCV). The objective of this research is to determine sociodemographic patterns of HCV-related ambulatory care visits over time. Data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey-Outpatient (NHAMCS-OPD) for the years 1997–2005 were analyzed in 3-year intervals. Demographic and other variables were compared for each period, and multivariable logistic regression was performed to examine whether the likelihood of a visit being HCV-related (versus non-HCV) was independently associated with (1) race and/or (2) Medicaid status over time. The total number of HCV-related ambulatory visits more than doubled from 3,583,585 during the years 1997–1999 to 8,027,166 during 2003–2005. During this time, the proportion of non-whites and Medicaid recipients presenting for HCV-related visits approximately doubled (non-whites: 16% vs. 33%, P = 0.04; Medicaid recipients: 10% vs. 25%, P = 0.07). In 2003–2005, HCV-related visits were more than twice as likely to occur among non-white patients vs. white patients (OR = 2.49; 95% CI: 1.60–3.86) and patients on Medicaid vs. non-Medicaid (3.49; 1.79–6.80). Our results show that HCV-associated ambulatory care visits are increasing, with a greater proportion of visits occurring among non-white patients and Medicaid recipients.
            Cover page: Sociodemographic Trends in National Ambulatory Care Visits for Hepatitis C Virus Infection
            • Article
            • Peer Reviewed
            UC San Francisco Previously Published Works (2009)
            Poor and non-white patients are disproportionately infected with the hepatitis C virus (HCV). The objective of this research is to determine sociodemographic patterns of HCV-related ambulatory care visits over time. Data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey-Outpatient (NHAMCS-OPD) for the years 1997-2005 were analyzed in 3-year intervals. Demographic and other variables were compared for each period, and multivariable logistic regression was performed to examine whether the likelihood of a visit being HCV-related (versus non-HCV) was independently associated with (1) race and/or (2) Medicaid status over time. The total number of HCV-related ambulatory visits more than doubled from 3,583,585 during the years 1997-1999 to 8,027,166 during 2003-2005. During this time, the proportion of non-whites and Medicaid recipients presenting for HCV-related visits approximately doubled (non-whites: 16% vs. 33%, P=0.04; Medicaid recipients: 10% vs. 25%, P=0.07). In 2003-2005, HCV-related visits were more than twice as likely to occur among non-white patients vs. white patients (OR=2.49; 95% CI: 1.60-3.86) and patients on Medicaid vs. non-Medicaid (3.49; 1.79-6.80). Our results show that HCV-associated ambulatory care visits are increasing, with a greater proportion of visits occurring among non-white patients and Medicaid recipients.
              Cover page: Sociodemographic Trends in National Ambulatory Care Visits for Hepatitis C Virus Infection
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2015)

              Background and aims

              Emergency Departments (ED) can serve as a gateway to specialty care for patients with cirrhosis with limited care access. We described the rates and characteristics of patients with cirrhosis who access United States (US) EDs, and identified factors associated with subsequent hospitalization.

              Methods

              Using data from the National Hospital Ambulatory Medical Care Survey, cirrhosis-related ED from 2000 to 2009 were identified and compared to all other ED visits.

              Results

              From 2000 to 2009, there were an estimated 1,029,693 cirrhosis and 877 million non-cirrhosis visits. Compared to the general ED population, those with cirrhosis were more frequently male (58 vs. 44 %, p = 0.02), Hispanic (18.6 vs. 10.6 %, p < 0.05), seeking care in urban areas (91.6 vs. 73.4 %, p < 0.05) and had Medicaid/no insurance (43 vs. 35 %, p < 0.01). Patients with cirrhosis were more frequently triaged immediately or emergently (72.3 vs. 54.2 %, p < 0.01). The majority were admitted or transferred to another hospital (66.8 vs. 17.4 %, p < 0.01). Among patients with cirrhosis, patients with age ≥ 65 years were more likely to be admitted (adjusted OR 2.49, 95 % CI 1.08-5.73), and Medicaid/uninsured (adjusted OR 0.34; 95 % CI 0.17-0.67) were less likely to be admitted, after adjusting for patient demographics, hospital characteristics, and triage score.

              Conclusions

              Patient with cirrhosis account for approximately 100,000 US ED visits annually. The higher admission rates among patients with cirrhosis indicate a high acuity of illness. Older age among those admitted may reflect poorer functional status. Finally, high visit but low admission rates among those with Medicaid/no insurance suggest a gap in specialty care.
                Cover page: High Rate of Hospital Admissions Among Patients with Cirrhosis Seeking Care in US Emergency Departments
                • Article
                • Peer Reviewed
                UC San Francisco Previously Published Works (2005)
                To determine patterns and predictors of antimicrobial drug use for outpatients with community-acquired pneumonia, we examined office visit and pharmacy claims data of 4 large third-party payer organizations from 2000 to 2002. After patients with coexisting conditions were excluded, 4,538 patients were studied. Despite lack of coexisting conditions, fluoroquinolone use was commonly observed and increased significantly (p < 0.001) from 2000 to 2002 (24%-39%), while macrolide use decreased (55%-44%). Increased age correlated with increased fluoroquinolone use: 18-44 years (22%), 45-64 years (33%), and > or =65 years (40%) (p < 0.001). Increased use of fluoroquinolones occurred in healthy young and old patients alike, which suggests a lack of selectivity in reserving fluoroquinolones for higher risk patients. Clear and consistent guidelines are needed to address the role of fluoroquinolones in treatment of outpatient community-acquired pneumonia.
                  Cover page: Antimicrobial Drug Prescribing for Pneumonia in Ambulatory Care - Volume 11, Number 3—March 2005 - Emerging Infectious Diseases journal - CDC
                  • Article
                  • Peer Reviewed
                  UC San Francisco Previously Published Works (2016)

                  Rationale, aims and objectives

                  Specialty care referrals have doubled in the last decade. Optimization of the pre-referral workup by a primary care doctor can lead to a more efficient first specialty visit with the patient. Guidance regarding pre-referral laboratory testing is a first step towards improving the specialty referral process. Our aim was to establish consensus regarding appropriate pre-referral workup for common gastrointestinal and liver conditions.

                  Methods

                  The Delphi method was used to establish local consensus for recommending certain laboratory tests prior to specialty referral for 13 clinical conditions. Seven conditions from The University of Michigan outpatient referral guidelines were used as a baseline. An expert panel of three PCPs and nine gastroenterologists from three academic hospitals participated in three iterative rounds of electronic surveys. Each panellist ranked each test using a 5-point Likert scale (strongly disagree to strongly agree). Local panellists could recommend additional tests for the initial diagnoses, and also recommended additional diagnoses needing guidelines: iron deficiency anaemia, abdominal pain, irritable bowel syndrome, fatty liver disease, liver mass and cirrhosis. Consensus was defined as ≥70% of experts scoring ≥4 (agree or strongly agree).

                  Results

                  Applying Delphi methodology to extrapolate externally developed referral guidelines for local implementation resulted in considerable modifications. For some conditions, many tests from the external group were eliminated by the local group (abdominal bloating; iron deficiency anaemia; irritable bowel syndrome). In contrast, for chronic diarrhoea, abnormal liver enzymes and viral hepatitis, all/most original tests were retained with additional tests added. For liver mass, fatty liver disease and cirrhosis, there was high concordance among the panel with few tests added or eliminated.

                  Conclusions

                  Consideration of externally developed referral guidelines using a consensus-building process leads to significant local tailoring and adaption. Our next steps include implementation and dissemination of these guidelines and evaluating their impact on care efficiency in clinical practice.
                    Cover page: Optimizing the pre‐referral workup for gastroenterology and hepatology specialty care: consensus using the Delphi method
                    • Article
                    • Peer Reviewed
                    UC San Francisco Previously Published Works (2014)

                    Objectives

                    This study aimed to estimate the incidence of emergency department (ED) visits in the neonatal period in a nationally representative sample and to examine variation by race.

                    Methods

                    The National Hospital Ambulatory Medical Care Survey is a nationally representative survey of utilization of ambulatory care services including EDs. We studied all ED visits for patients who were younger than 28 days old from 2003 to 2008. Using the national birth certificate data, we calculated the visit rates by race. Emergency department visits were also characterized by age, insurance status, diagnosis category, region, and hospital type (safety-net vs non-safety-net hospitals).

                    Results

                    There was an average of 320,540 neonatal ED visits in the United States per year, with an estimated 7.6% of births visiting the ED within 28 days. Estimated rates of ED visits were highest among non-Hispanic blacks, with 14.4% (95% confidence interval [CI], 10.0-19.2) of newborns having an ED visit in the neonatal period, compared with 6.7% (95% CI, 4.9-7.2) for whites and 7.7% (95% CI, 5.7-9.8) for Hispanics. Hispanic and black neonates were more likely to be seen in safety-net hospitals (75.8%-78.2%) than white (57.1%) patients (P = 0.004).

                    Conclusions

                    In this first nationally representative study of neonatal visits to the ED, visits were common, with the highest rates in non-Hispanic blacks. Hispanic and black neonates were more commonly seen in safety-net hospitals. Reasons for high visit rates deserve further study to determine whether hospital discharge practices and/or access to primary care are contributing factors.
                      Cover page: Emergency Department Visits in the Neonatal Period in the United States
                      Top