Principles of Ambulatory Medicine [antikvár]

Chapter 1 / Ambulatory Care, Evidence-Based Medicine, and Oilier Core Proficiencies for Ambulatory Practice 3 CHAPTER 1 Ambulatory Care, Evidence-Based Medicine, and Other Core Proficiencies for Ambulatory Practice L. RANDOL BARKER, MD JOHN C. ROBERTS, MD Domain of Ambulatory Care 3 Office-Based Generálist Physicians 3 Ambulatory Patients 3 Problems of Ambulatory Patients 3 Ambulatory Care 3 Self-Care and Alternative Care 4 The Temporal Dimension of Ambulatory Medicine 5 Goals of Ambulatory Care 7 Practicing Evidence-Based Medicine 7 The Diagnostic Process 7 Treatment 10 Prognosis 12 Keeping Up 12 Other Core Proficiencies for Ambulatory Practice 13 Clinical Pharmacology 13 Communication and Patient Education 14 Documentation of Care 14 Coordination of Care 14 Discharge Planning 14 Cost Containment and Managed Care 16 The fundamental tenet of this book is that ambulatory care has distinctive characteristics that should shape physicians' approaches to patients. This chapter describes the domain of ambulatory care in the United States. It also addresses In detail the evidence-based practice of medicine, and it describes briefly other proficiencies that are central to ambulatory medicine. DOMAIN OF AMBULATORY CARE Who are the physicians providing ambulatory care? What patients visit physicians in their offices? What problems do these patients present to their physicians? What ambulatory care is provided for these problems? To answer these questions, the United States National Ambulatory Medical Care Survey (NAMCS), started in 1973, has collected information periodically from a representative sample of physicians' offices. Office-Based Generalist Physicians Table 1.1 shows the distribution by physician specialty of the nearly 670 million office visits to physicians in the United States during 1991. Of these visits, approximately 15% were to internists and 25% were to general/family practitioners, the groups of generalists to whom this book is directed primarily. Ambulatory Patients The NAMCS definition of an ambulatory patient is "an individual presenting for personal health services who is neither bedridden nor currently admitted to any health care institution." A critical expansion of this definition is that ambulatory or homebound patients (or members of their households) have most of the responsibility for carrying out their own care: They must administer most or all treatments, must monitor symptoms and functional status, must adapt activity to the constraints imposed by illness, and must decide how to deal with new problems when they arise. These characteristics have important implications for the care of ambulatory patients, as discussed below. The age and sex distribution of the patients who visit internists and general/family practitioners is shown in Table 1.2. Approximately 60% of visits to all generalists are made by female patients. The principal differences shown in Table 1.2 are that adolescents and young adults account for a larger proportion of visits to general/family practitioners than to internists, and that visits by older patients make up a larger proportion of the practice of internists. Problems of Ambulatory Patients What types of problems are seen in ambulatory practice? Physicians participating in NAMCS were asked to name the principal reasons (using the International Classification of Diseases) for the visits by patients. Table 1.3 lists the most common responses given by internists and general/family practitioners, respectively. Ambulatory Care The NAMCS defines ambulatory care as "health services rendered to individuals under their own cognizance, any time when they are not in a hospital or other health care institution." In 1989, the annual number of office visits by adults to all types of physicians ranged from 1.9 for people 19 to 24 years old to 5.9 for people aged 75 and over. Table 1.4, fi:om the 1989 NAMCS report, shows the frequency of the therapeutic services that are most commonly provided or ordered at ambulatory visits by internists and general/family practitioners: medications and counseling. The table also shows the frequency distributions of visit duration, visit status of