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Q  T  W  ??] i y? ;n>n??y(z))`2)I?2 G2 70?1 ?  2??  2?  2?0   2  P  R  V  \  ?^? ?n> h??m s&'' Y??2 P?2K2;2  2? ? 2? ?# 9+ P+ ?R+ ?T+ [+ ?Z  b   ?s?; ??s>r$$j2$Z??2?? 2??24? 2'> ?2$8 3 ?3 ?! 3???+ Q. ?Q?. Q?. Q??_?z'?w???? !p83!f3"Y8?3E8?2?3 ?>2,? 2?* 2*? 2 ??8 * P+ P+ P+ ?Q+ ? U+ \+?i+??}8+?} +w??{t3p?2]? 2Y? 3E?30??? 30 3?/ 3 ??/ 3/? Q/? Q?/? U0?  X0 b0?_ 0s` 0?`n 1?s8y3w3d <3`? 3`?36?? 2? ?4? 2 04 2x3 33 R3 8R3  ?X4 ?8]4f4??[< ???5 q85>?n5p6<z|3z3l?3d? 2b3? A?3:  N8 N8 N8 N8? ?K?8? ?/?x ?8 6 > 8 # +93/98?;9??:G9@G>FHJJv?J+@>?J(?<?J {:J  (J?> J  J= J=  ?I=  I=  I=  > I= ?>I= I= 4I>?I> GH>W?H>W?H>WH>=` H>< ?? ?H>)H?8H???G?? ?G? G? G? G? G? ?  G?? G??F@?F@ 6F@ ?>F@FF@WF@WF@B8F@; >F@:FA( EA? EA ?EA ?EA EA EA EA EB EB  ?EB ~DB ?,?DB3DBBDBWDCWDCVDC2?DC, ?;?DC,CC~?,CC;CCDECDFCDFCDFCDEBD9>?BD* <??BE? BE pBE 4BE?8BEVBEVBERBEG ? ?AE;>?AE4AF1$AF +AF 8AFDAFF@FE?@FE@FE@F;?@F/?@G?  @G ?+?G ?4??G p>>8?GA?GW?GM8?HF?H7??H. ??H8x<(>H>??.?>HE?>HF>IF>IF>I F>I F>I ;?>I )>I x8=I 3?=I3?=J?C=JA=JP=JN?UJ?>UJ>U7>V4x>>V0<>V >V>V>V?>V8'>V4?=W5?=W7======<?<<<<<<<<<?;;:?:::::: ?:;?FIJ g"  _ ӀTable1:Definitionofpatientgroups   .*V ddd Xdd Xdd X((,Hdd ,dd ,ldd ,dd +  /jjjdbbbb //XXGroup# Ajjd,!"jjjd AResidence Ajjd,!"jjd AModeofcontact Ajjjd,!"jjd Atotal# ZjK!"jjjd  ?1?Z1 TJ?"  ?1 ?j TYerevan '" 'phone Pj= "  I@50I@P50 ~jo@ "  I@50 I@j e @2@~2 TJ?tt "  @2 @j TYerevan 'tt " 'mail Pj=tt "  G@46G@P46 ~joEtt"  G@46 e G@j  @3@~3 TJ?"  @3 @j TArmenia(outsideof  Yerevan) '" 'mail Pj="  H@49H@P49#XX/#/XX yjj@"  H@49 H@j  @4@y4 TJ?"  @4 @j TGeorgia '" 'mail Pj="  A@35A@P35#XX/#/XX {jjj@"  A@35 A@j  @5@{5 [jJ?M M "  @5 @jj [Russia =j,!M M "j =mail _jjL!M M "j  1@171@_17#XX/#PFDM M "  1@17  1@jj PĺTABLE D 8$    7    _/XX0 ` Thenumberofsurgicalpatientsin19992001isapproximately1,600.#XX/S#8y61Triangles  X   2(4 4 <DL!2      5+ 4 <DL!5  XXX   8$    6    _/XX0 ` SeeAppendix3fordetailedcalculations#XX/S#mTTABLE F ; 8$    9    _/XX0 ` Basedondatathatshowthat40%ofNMMCsurgicalpatientsarefromYerevan,and40%of X Yerevanpatientswillnotrespondtomailed#XX/S#/XXquestionnaire.[1,600x0.4x0.4=256Yerevan  patientstobecontactedin2002;therefore,5patientsperweekmustbecontactedby_phone]#XX/9#_TABLE GH i) 8$    8    /XX_0 ` 30patientsperweekx70%estimatedresponse_rate#XX/C#_ !  _  (# (#(#(# W(83 *4XXXX    ?+ 4 <DL!X?0DL!X0_OKx|dp/%@Z********dE::PG߀  Ѐ 4LjJX4X#L JJ4Lj#4LjJ JLAmericanUniversityofArmenia#4XXJ4LjF##XXX4Xň#4XXXX  ЀCenterforHealthServicesResearch 0   (# (#(#(# E+ 4 <DL!DXE X  h  (#(# (# (# X&        ]I4` <hDp x (#X]    4XXX4X    X      X/  Ԍ̌    $ X, X$    4XXX4X    ' @  4RcQX4X#RZQQ4Rc #4RcQQRZ  #4XXQ4RcD##XXX4Xņ#4XXXX          4XXX4XXXX4X    A  #XXXX#XX FeasibilityStudyforaPatientFollowUpCenteratA݌ l Ќ  XX4XXXX   4X4XNorkMarashMedicalCenter #4XX4#XXX4X  #4XXXXV #5 4X4X  #4XX4 #  & p     4X4X    B   B   Ԍ̌  4XX4   'p6   4͍X4X  #4XX4͍^ #4RcQX4X    #4XXQ4Rc #4͍X4X  #4XX4͍ #AmericanUniversityofArmeniaand +'" NorkMarashMedicalCenter ,'#      June2001  -($ 4LjJX4X*k_OKx|dep/%@Z********dEe::PG;  (# (#(#(#AmericanUniversityofArmenia#4XXJ4Lj # X ЀCenterforHealthServicesResearch P   (# (#(#(# ?+ 4 <DL!X? X 8  (#(# (# (# X&        ]I4` <hDp x (#X]    4XXX4X    \      \3  Ԍ̌    $ X, X$    4XXX4X    ' D  4RcQX4X  #4XXQ4RcH#           4XXX4XXXX4X      pXX pFeasibilityStudyforaPatientFollowUpCenteratp݌ <  Ќ  XXXXXX4XXXX   XXX4X#XXXX#XXNorkMarashMedicalCenter#p۱# #XXp#pXX  R^ #XXpv#pXX  #XXp#pXX  &      pppp        Ԍ̌  pppp   'ju  #XXpJ##XX  #XX##R2%QXX    #XX%QR2S##XX  #XX##XXXXAmericanUniversityofArmeniaand +N'! NorkMarashMedicalCenter ,6("    June2001  -)#  ** 8XXdd8    #XXXX#4XXXX?+ 4 <DL!X?    4XXX4XXXX4X      #XX###~#4͍#AcknowledgmentM݌  Ќ  4XX4͍4XXX4X   #4XXX4X{##XXX4XŽ#4XXXX      4XXX4XXXX4X      #XXXX#XXXXz݌̌  XXXX4XXXX   XXX4X      XXXXXXXX    XXXX  Thecontributionofselectedindividualstotheproductionofthisreportisgratefully  acknowledged.݌  Ќ  XXXXXXXX       XXXXXXXX    XXXXD  D݌̌  XXXXXXXX       XXXXXXXX    XXXXz   FromtheCenterforHealthServicesResearch(CHSR),SerinehVoskanian,CHSRIntern,lead t  theefforttodesignandimplementthefeasibilitystudythatformsthebasisofthereport.Other `  CHSRlocalstaffplayedimportantrolesintheimplementationoftheprojectandinwritingthe L  report.z !݌ 8  Ќ  XXXXXXXX       XXXXXXXX    XXXX%#  %##݌̌  XXXXXXXX       XXXXXXXX    XXXX[$  FromtheNorkMarashMedicalCenter(NMMC),anumberofindividualsworkedalongside `  CHSRcounterpartsintheconductofthisstudy.Inparticular,personnelfromtheAdultCardiac L  Clinicprovidedagreatdealofassistancetothiseffort.SomeofthekeyNMMCstaffwho 8  formedpartofthestudyteamarenamedinAppendix2ofthisreport.Otherpersonnelat $  NMMCwhoassistedinthiseffortbutarenotnamedhereareacknowledgedfortheirefforts.[$$݌   Ќ  XXXXXXXX   #XXXX#XXXX    %  #XXXX'# $dXX$  #XXؾ+#T-+ؾTableofContents #XX-T(#  (   10 d 0d(#d(#Introduction#""J(#.J J (#(##2   !  !)0 d 0d(#d(# d   1.1  Background#""J(#. (#(##2!))݌  Ќ  !  !*0 d 0d(#d(# d   1.20(#(#FollowupcareforsurgicalpatientsatNMMC:Currentpractice#""J(#.N(#(##2!**݌  Ќ  !  !+0 d 0d(#d(# d   1.30(#(#Reportstructure#""J(#.^ ^ (#(##3!++݌ t  Ќ  Vm  Vm,0 d    20dd(#d(#0d(#d(#Projectdescription#""J(#.^ ^ "(#(##3 Vm,,݌ L  Ќ  !  !-0 d 0d(#d(# d   2.10(#(#Projectgoalsandobjectives#""J(#.,(#(##3!--݌ 8  Ќ  !  !.0 d 0d(#d(# d   2.20(#(#Projectoverview#""J(#. (#(##3!..݌ $ t  Ќ  Vm  Vm/0 d    30dd(#d(#  Methodology#""J(#.j j d(#d(##4 Vm//݌ L  Ќ  !  !00 d 0d(#d(# d   3.10(#(#Studyparticipants#""J(#. "(#(##4!00݌ 8  Ќ  !  !{10 d 0d(#d(# d   3.20(#(#Patientgroups#""J(#. (#(##4!{11݌ $  Ќ  !  !j20 d 0d(#d(# d   3.30(#(#Respondentselectionprocess#""J(#.jj,(#(##4!j22݌   Ќ  !  !g30 d 0d(#d(# d   3.40(#(#PatientFollowupQuestionnaire(PFQ)#""J(#.4(#(##5!g33݌   Ќ  !  !l40 d 0d(#d(# d   3.50(#(#Contactprocedures#""J(#.h h "(#(##5!l44݌  Ќ    _50 d 0d(#d(#0` (#(#    3.5.10` ` (#` (#Methodsformailsurvey#""J(#.>>,` (#` (##5_5z5݌  Ќ    g60 d 0d(#d(#0` (#(#    3.5.20` ` (#` (#Methodsforphonesurvey#""J(#.-` (#` (##5g66݌ p Ќ  !  !p70 d 0d(#d(# d   3.60(#(#Dataentryprocedures#""J(#.JJ%(#(##5!p77݌ \ Ќ  !  !f80 d 0d(#d(# d   3.70(#(#StudyTeamcomposition#""J(#.&(#(##6!f88݌ H Ќ  Vm  Vm]90 d    40dd(#d(#0d(#d(#Results#""J(#. (#(##6 Vm]9y9݌  p Ќ  !  !D:0 d 0d(#d(# d   4.10(#(#Responserates#""J(#. (#(##6!D:_:݌  \ Ќ  !  !3;0 d 0d(#d(# d   4.20(#(#ParticipantsresponsestoquestionsonthePFQ#""J(#.jj?(#(##6!3;N;݌ H Ќ    F<0 d 0d(#d(#0` (#(#    4.2.10` ` (#` (#Interpretationofdata#""J(#.""+` (#` (##7F<a<݌ 4 Ќ    M=0 d 0d(#d(#0` (#(#    4.2.20` ` (#` (#ImplicationsofresultsfromquestionnaireresponsesforestablishmentofPFUC#""J(#.v"v"c` (#` (##8M=h=݌   Ќ  Vm  Vm>0 d    50dd(#d(#0d(#d(#Conclusions #""J(#.F F (#(##8 Vm>>݌  Ќ  !  !}?0 d 0d(#d(# d   5.10(#(#AdvantagesanddisadvantagesofestablishingaPFUC#""J(#.C(#(##8!}??݌  Ќ  !  !@0 d 0d(#d(# d   5.20(#(#Anticipatedresponserates#""J(#.*(#(##9!@@݌   Ќ  !  !A0 d 0d(#d(# d   5.30(#(#ProposedmodelforaPFUC#""J(#.@@)(#(##9!AA݌ p! Ќ  !  !B0 d 0d(#d(# d   5.40(#(#CostofestablishingandimplementingaPFUCatNMMC#`"`"I(#.llD(#(##12!BB݌ \"  Ќ  !  !C0 d 0d(#d(# d   5.40(#(#ImplementationscheduleforestablishmentofPFUCandmanagementresponsibilities#`"`"I(#.""`(#(##15!CC݌ H#! Ќ  Vm  VmD0 d    60dd(#d(#0d(#d(#RecommendationsandSummary#`"`"I(#.*(#(##15 VmDD݌  %p # Ќ  Vm  VmE0 d    Appendix1:Questionnairesusedinstudy(English,Armenian,Russian)#`"`"I(#.Od(#d(##16VmEE݌ &H"% Ќ  Vm  VmF0 d    Appendix2:CompositionofStudyTeam#`"`"I(#.XX/d(#d(##22VmFF݌ ( $' Ќ  Vm  VmG0 d    Appendix3:Calculationsofpersonnelneeds#`"`"I(#.5d(#d(##23VmGG݌ *%) Ќ  Vm  VmtH0 d    Appendix4:CostofmailpacketsforPFUC#`"`"I(#.003d(#d(##24 VmtHH݌ ,'+ Ќ  U)  l-(, X  >@# 10 d 0d(#d(#Introduction  I (#(#  (j88W  " t."   t.J2j1.  1  3  0    Background J t.JJ݌(#(# Ќ  aLeadinghealthfacilitiesaroundtheworlddevelopandimplementsystemsthatallowthemto r monitortheirpatientshealthstatusandbehaviorsovertime.Afollowupprogramisanintegral ^ aspectofhighqualitycomprehensivecareforpatientswhohaveundergonecardiacsurgery.A J  patientfollowupcenter(PFUC)atafacilityprovidingcardiacsurgicalserviceshastwoprimary 6  objectives.Thefirstobjectiveiscenteredontheindividualpatientwhohasreceivedcareatthe " t facility;theperiodiccollectionofdataonthepatientshealthstatusandbehaviorsallowsforthe  ` facilitytomonitorthepatient,providehimwithqualitycare,andminimizetheriskoffurther  L  hospitalizationsandcomplications.ThesecondobjectiveofaPFUCconcernstheuseof  8  aggregatedfollowupdatatoevaluatetheoutcomesofcare;researchbasedonaggregateddata $  canbeusedtoevaluatetheeffectivenessofnewtechniquesordevicesortoidentifyproblemsin   patientcaremanagement. d Forexample,theStarrClinicinPortland,OregonestablishedaPFUC   inordertoevaluatethelongtermeffectivenessofartificialheartvalves.d   RepresentativesfromtheAmericanUniversityofArmenia(AUA)andtheNorkMarashMedical n Center(NMMC)heldpreliminarydiscussionsinDecember1999toidentifyareasfor Z cooperationundertheframeworkoftheAUA/NMMCProject(ANP).Thelackofstandardized F protocolsforthefollowupofpatientswhoundergocardiacsurgeryatNMMCwasidentifiedby 2 NMMCpersonnelasaweakpointofNMMCsactivities.Agreementwasreachedbetween p AUAandNMMCtoconductasmallstudytodeterminethefeasibilityandcostofestablishinga  \ PFUCatNMMC.Thisreportdocumentstheresultsofthatstudy. H   1.20  FollowupcareforsurgicalpatientsatNMMC:Currentpractice (#(#  SPostsurgeryfollowupcareatNMMCisprovidedinmuchthesamewayforadultsandchildren.   Thepatientsfirstfollowupvisitisalwaysscheduledfortheseconddayfollowinghisorher  dischargefromthehospital.Generally,thesecondfollowupvisittakesplacewithinsevendays  ofthefirstvisit.Allsurgicalpatientsaregenerallyseenforfollowupcareatleastonceper ~ monthforthefirstsixmonthsfollowingtheirdischarge.Apartfromthesegeneralguidelines,the j frequencyofandintervalbetweenfollowupvisitsduringthefirstsixmonthspostsurgeryare V  determinedonacasebycasebasisanddependonthepatientshealthstatus,diagnosis,andthe B! typeofsurgerythatwasperformed.Followupcareisprovidedfreeofchargeduringthisperiod ."  toencouragepatientstoattendtheirappointments. #l! Aftersixmonthsthescheduleoffollowupcareisbasedontheindividualpatientsrehabilitation $D # processandisnotformallydefinedbyNMMC.Somegeneralguidelinesdoexist;forexample, %0!$ patientswhohaveundergonethecoronaryarterialbypassgraft(CABG)procedureareseenat &"% leasttwiceperyearinthefirsttwoyearspostsurgeryandonceperyearthereafter.Patientswho '#& haveundergonevalvereplacementsurgeryattendfollowupvisitsatNMMCapproximatelyonce (#' everymonthtobetestedforbloodcoagulation. )$( TherearenostaffmembersatNMMCwhohavebeenclearlyassignedtheresponsibilityto f+&* maintaincommunicationwithpatientsfollowingtheirsurgery;thatis,tomonitortheirhealth R,'+ status,arrangetheirfollowupvisitsandcontactthembypostorphonetoencouragethemto >-(, attendthesevisits.CardiologistsatNMMCstatethat!forapproximatelytwoyearsfollowing  theirsurgery!patientsareinformallyencouragedtoattendfollowupvisitsandare remembered  byNMMCpersonnel.Afterthesecondyearoffollowupcarepatientsare ontheirownand  musttaketheinitiativetoarrangeanysubsequentfollowupcare. r SpecialconsiderationregardingfollowupcareisgiventosurgicalpatientsatNMMCwhodo J  notliveinYerevan!i.e.,thosepatientswholiveeitherintheregionsofArmeniaorinother 6  countriesoftheregion.ThesepatientsgenerallyremainatNMMCasinpatientsseveraldays " t longerthanpatientswholiveinYerevaninordertoensurethattheyhavefullyrecoveredfrom  ` theirsurgerypriortobeingdischargedfromthehospital.Aftertheirdischarge,itis  L  recommendedtothesepatientsthattheyremaininYerevan(orreturntoYerevanfromtheir  8  homes)onemonthfollowingtheirsurgeryforafollowupvisit.Eachofthesepatientsisgivena $  detaileddischargesummarytoguidetheprovisionoffollowupcarebytheirlocalprovider.     1.30  Reportstructure (#(#  aThisreportisstructuredinthefollowingmanner.Thefirsttwosectionsofthereportconsistof   anintroductiontotheprojectandadescriptionofitscomponentsandobjectives.Adescription n ofthemethodologyisthenfollowedbyapresentationoftheresultsofthedatacollection Z exercise.Thereportcloseswithconclusionsandrecommendationsregardingtheestablishment F ofaPFUCatNMMC. 2   20 d 0d(#d(#Projectdescription dH(#(#   2.10  Projectgoalsandobjectives (#(#  dThegoalofthePatientFollowUpCenterProject(PFUCP)istoprovideinformationthatcanbe   usedbytheANPSteeringCommittee(SC)to1)determinewhetherornottoattempttoestablish  aPFUCatNMMCand2)proposeafeasible,lowcostmodelforaPFUC,shouldadecisionbe  takentoestablishaCenter. ~ ThefollowingobjectiveshaveguidedthedesignandimplementationofthePFUCP: V  ! ! (588" t."   t.g25  1  .3  0 d   ToproposeamodelforthedesignandimplementationofaPFUCatNMMC,takinginto ."  accountcurrentdesignsofpatientfollowupcentersintheWestandtherealitiesof #l! establishingaPFUCinNMMC. t.gg݌$X"d(#d(# Ќ  " t."   t.Ai25  2  .3  0 d   Toestimatetheresources(bothcapitalandrecurrent)requiredtoestablishandoperatea $D # PFUC. t.Aini݌%0!$d(#d(# Ќ  " t."   t.~j25  3  .3  0 d   Toestimatetheanticipatedresponserateofpatientstofollowupefforts. t.~jj݌&"%d(#d(# Ќ   2.20  Projectoverview(#'(#(#  iokThisparagraphbrieflydescribesthemajoractivitiesofthePFUCP.Differentgroupsofpatients )$( whohadundergonecardiacsurgeryatNMMCin1999wereidentified.Patientgroupswere z*%) definedbasedontwofactors:1)theirplaceofresidence(forexample,patientslivinginYerevan, f+&* orpatientslivinginArmeniaoutsideofYerevan),and2)themannerinwhichmembersofthe R,'+ groupwerecontactedtofilloutthePatientFollowupQuestionnaire(membersofeachgroup >-(, wereeithersentaselfadministeredquestionnairebymailorwerecontactedbyphoneandasked  torespondtothequestionsoverthephone).Datafromcompletedquestionnaireswereentered  intoadatabase,aggregatedandanalyzed.Findingsfromtheanalysiswerecomplementedby  suggestionsfrommembersoftheANPSteeringCommitteeinordertogenerateamodelfor r establishingaPFUCatNMMC. ^   ! ! [(98 30 d   Methodology io&p" td(#d(# TheStudyTeam(i.e.,AUAandNMMCpersonnelimplementingtheproject)soughttoachieve  ` theobjectivesofthePFUCPthroughtheimplementationofacarefullyconstructedstudydesign.  L  Differentaspectsofthedesignthatwasfollowedaredescribedbelow.  8    3.10  Studyparticipants (#(#  ioorStudyparticipantswereadultindividuals(agedgreaterthan15years)whounderwentsurgeryat   NMMCin1999.Studyparticipantswereselectedfromacomprehensivelistofalladultsurgical   patientsfrom1999thatwasprovidedbytheAdultOutpatientCenteratNMMC.Proceduresthat   wereusedtoselectstudyparticipantsfromthislistaredescribedbelow. n   ||D40l~((  `E(I( y( (I( | (((#(#3.20  PatientgroupsF((#  iotAdultsurgicalpatientsat 2 NMMCweredividedintofive p differentgroups,basedon1)  \ theirplaceofresidenceand2) H themannerofcontactingthem 4 forthepurposeofhavingthem   completeaPatientFollowup   Questionnaire(PFQ).The  groupsaredelineatedinthetable  totheright. ~  (#(#((  3.30  RespondentselectionprocessB!(#(#  iowItwasdecidedtoattempttoincludefiftyrespondentsineachgroup.Thenumberfiftywasfeltto ."  besufficientlylargeenoughtoallowforanticipatedresponseratestobecalculatedwith #l! reasonableprecisionwhilekeepingthestudylogisticallymanageableD 9#  1      .Respondentswere $X" selectedinthefollowingmanner.TheAdultOutpatientClinicatNMMCprovidedthestudy $D # teamwithalistofalladultpatientswhohadundergonesurgeryatNMMCinthecalendaryear %0!$ 1999.Beginningfromtheendofthelist(i.e.,withthelastpatientoperatedonin1999)patients &"% wereassignedtothefivestudygroupsusingthefollowingguidelines: '#& ! !  (Ax9[" t."   t.{2A3  0 d   ThelastonehundredpatientsonthelistwholivedinYerevanwereincludedinthestudy. )$( ThesepatientswereassignedalternatelytoGroups#1and2. t.{'|݌d(#d(# Ќ  " t."   t.]}2A3  0 d   ThelastfiftypatientsonthelistwholivedinArmeniabutoutsideofYerevanwereincludedin  thestudyandwereassignedtoGroup3. t.]}}݌d(#d(# Ќ  " t."   t.~2A3  0 d   AllpatientsonthelistwhoresidedinGeorgia(n=35)wereincludedinthestudy. t.~~݌rd(#d(# Ќ  " t."   t.2A3  0 d   AllpatientsonthelistwhoresidedinRussia wereincludedinthestudy. t.݌^d(#d(# Ќ   [(9x y{% X{%  (Ax9[! !% % [(9x i! ! c (fx9[Thefollowingpatientswereexcludedfromthestudy: :  % % [(9xc ׂ! ! (89[" t."   t.2  1  .3  0    PatientswhowerefromcountriesotherthanRussia,ArmeniaorGeorgia;and, t.(݌& x(#(# Ќ  " t."   t.2  2  .3  0    Patientswithaninsufficientaddressorphonenumber. t.>݌ d(#(# Ќ  ThenumberofpatientsinGroups2and3waslessthan50duetomissingorillegibleaddresses.  <    3.40  PatientFollowupQuestionnaire(PFQ) io (#(# ThequestionnairethatwasusedinthisstudywasbasedonthePFQthatiscurrentlyinuseatthe   StarrClinicinPortland,Oregon. AcopyofthePFQthatwasusedinthisstudy(inEnglish,   ArmenianandRussianlanguage)canbefoundinAppendix1ofthisreport.     3.50  Contactprocedures^(#(#  io`Proceduresthatwerefollowedinordertomakecontactwithstudyparticipantsareoutlined J below.Afirstroundofmailings/phonecalls(dependingonthegroup)wasconductedinearly 6 July2000.Asecondroundofmailings/phonecalls!limitedtoparticipantswhohadnot "t respondedtothefirstround!wasconductedinearlySeptember2000. `   3.5.10  Methodsformailsurvey8(#(#  iorLettersthatweresenttorespondentsinthefour mailgroups(i.e.,Groups25inTable1above) $ duringthefirstroundincludedareturnenvelopeaddressedtoNMMCandcopyofthe  questionnaire(inArmenianlanguageforletterssenttoArmenianpatientsandinRussianforall  otherpatients).Thereturnenvelopewasnotprestamped.Asecondroundofmailings(limited  tononrespondentslivinginArmeniafromfirstround)wassentinSeptember2000. Thereturn  envelopesusedinthesecondroundwereprestamped(witha40dramstamp)inorderto n encouragesurveyparticipantstorespond. Z    3.5.20  Methodsforphonesurvey2" (#(#  ioюPersistentattemptsweremadetocontacteachsurveyparticipantintheYerevanphonegroup #p! (i.e.,Group#1)duringthefirstroundofdatacollectioninJuly2000.Surveyparticipantswere  $\" phonedatdifferenttimesoftheday.Asurveyparticipantwasconsideredtobeanonresponseif $H # threeattemptstocontactthemdidnotyieldasuccessfulinterview.Allrespondentswhowere %4!$ contactedbyphoneagreedtoparticipateinthestudy.Identicalprocedureswerefollowedin & "% September2000whileattemptingtocontactthe19surveyparticipantswhohadnotbeen ' #& successfullyinterviewedinthefirstroundofthesurvey. (#'   3.60  Dataentryprocedures~*%)(#(#  ioIDatafromthequestionnaireswereenteredintoadatabaseinMicrosoftExcel.Analysisofthe j+&* datawascarriedoutusingthestatisticalsoftwarepackageStata(Version6.0). V,'+  B-(,   3.70  StudyTeamcomposition(#(#  ioTheInvestigativeTeamwascomposedofPublicHealthstudentsfromtheAmericanUniversity  ofArmenia(AUA),internsworkingintheCenterforHealthServicesResearch(CHSR)atAUA,  employeesofNMMCandtheANPProjectCoordinator.Namesoftheindividualswhoworked r onthisstudyarelistedinAppendix2. ^   40 d 0d(#d(#Results 6 (#(#  ioTheresultsfromthisprojectarepresentedintwosectionsinordertosimplifythepresentation. " t Thesesectionsarethefollowing:  ` ! ! G(h88" t."   t.P2h  1  .3  0 d   Responserates t.P}݌ 8 d(#d(# Ќ  " t."   t.'2h  2  .3  0 d   ParticipantsresponsestoquestionsonthePFQ t.'T݌$ d(#d(# Ќ   4.10  Responserates (#(#  A#Theresponserates(i.e.,percentagesofstudyparticipantswhosuccessfullycompletedthePFQ)   ineachofthefivepatientgroupsaredescribedinthetablebelow.    Table2:PercentagesofstudyparticipantscompletingPFQ,bypatientgroup  Z V*EVFddd Xdd Xdd X(#(#,wdd ,dd ,dd ,9dd ,Fdd ,Fdd ,dd +  3jjjd 3/XX# VjydA2 ^"!!jjjd VPatientgroup Hjjd3$ r"jyd Htotal##XX/m#/XX VjjdA24"j  jjd V#respondingto 4 firstround#XX/c#/XX VjjdA2"jmmjjd V#respondingto 4 secondround#XX/+#/XX VjjjdA2"jmmjjd V%responding#XX/#/XX VdA24 "j  jjjd V#XX/#/XX ;jd&){ d ;Residence Ajd,!!"jd AModeof " contact Ed0!O#"jd E ?d*){#d ? ?d*){#d ? ?d*){#d ? TjE){#d  ?1?T1 KA?$"  ?1 ?j KYerevan  % phone G=&"  I@50I@G50 f\1'"  I@50 I@  ?@31?@f31 e[1("  ?@31 ?@  @5@e5 Nj;0)"  @5 @ N72(36/50) ZjK!*"j  @2@Z2 KA?O+"  @2 @j KYerevan  O, mail G=O-"  G@46G@G46 f\1O."  G@46 G@  *@13*@f13 i_1O/"  *@13 *@  *@13*@i13 ^jK@O0"  *@13 *@ ^56(26/46) ZjK!O1"j  @3@Z3 KA?U2"  @3 @j KArmenia(outsideof U3 Yerevan)  k4 mail G=U5"  H@49H@G49 f\1U6"  H@49 H@  7@237@f#XX/1#/XX23 h^1U7"  7@23 7@  "@9"@h9 ]jJ?U8"  "@9 "@ ]65(32/49)#XX/P#/XX ZjK!U9"j  @4@Z4 KA?q:"  @4 @j KGeorgia  q; mail G=q<"  A@35A@G35 e[1q="  A@35 A@  @7@e#XX/d#/XX7 P;0q>"  @7 @ P ?j,!q?" ?20(7/35)#XX/##/XX \jjK!q@"j  @5@\5 RjA?A"  @5 @jj RRussia 4j#Bj 4mail ]jL!C"j  1@171@]17 {jj@D"  1@17 1@j  @4@{#XX/#/XX4 _jJ?E"  @4 @j _ ?jj,!F"j ?24(4/17)#XX/#1'%G"  jj 1  4.20  ParticipantsresponsestoquestionsonthePFQ"I(#(#  A$ThequestionsonthePFQaskedrespondentstoprovideinformationregardingtheirreported #J healthstatus,theirbehaviors,andtheircurrentmedicationregimes.Thesedatahavebeen m$K aggregatedbystudygroupandarereportedinthetablebelow.Dataregardingmedicationsare Y% L notpresentedinthisreport. E&!M   1'"N  Table3:Aggregatedresponses(expressedin%)ofstudyparticipantstoindividual  questionsonthePatientFollowupQuestionnaire   Ӏ  *JVKddwdd wdd dd 9dd 9Fdd FFdd Fdd EVF(#(#,,dd ,dd ,Sdd , dd , dd , dd , dd , dd +  /XX 3jjjdNN 3#XX/#/XX##XX/i#/XX VjjdA26" jjjd VQuestion#XX/#/XX VjjdA26 " jjd VResponses#XX/O#/XX VjjdA26 " jjd VPatientgroup(modeofcontact&residence) =3$` "jjd =#XX/#2XX % R  % % R  % ,yd R  ,Phone Eyjd0!"yd EMail =3$"yjd = %   % %   % ,jd   ,Yerevan  X (n=36) Ajd,!~ "jd AYerevan  X (n=26) Ajd,!~ "jd A#XX2#u4XXArmenia#XX4us#2XX  X regions   (n=32) Ajd,!~ "jd AGeorgia  X (n=7) Ajjd,!~ "jd ARussia  X (n=4) QjB!~ "jjd  ?1?Q1 B86   ?1 ?j B  E+ 4 <DL!dXEDoyouhaveangina    pectoris(chestpain,  ! discomfortortightness B " occasionallyspreading N # toarmsorjaw)?  $   ?+ 4 <DL!X?Never  %  Withsevereexertion w &  VB.2 W2 <DL!XB  Withordinaryexertion  r '   VH+ 4 <DL!2 W2 XH  Withtheslightestactivity  ( Noresponse ' ) 'Ѐ64%  * 3  + 8 B , 25 N - Є ' ." 'Ѐ23%  / 12  0 42 B 1 19 N 2 4 ' 3" 'Ѐ41%  4 25  5 28 B 6 3 N 7 3 ' 8" 'Ѐ57%  9 Є43 B ; Є̄ 0j =" 0Ѐ25%  > 50  ? Є25 N A Є QjB! B"j  @2@Q2 B86V C  @2 @j B  ?+ 4 <DL!X?Underwhatcondition(s) V D doyouexperience  E shortnessofbreath? x F Never V G Withsevereexertion  H Withordinaryexertion x I Withtheslightestactivity B8 2J 2!A5888252!AB58 V K 8  L 8 x M 25 pf52N" 2!A588825 2!A 0}A312323230}Ap31 V O 23  P 23 x Q 23 rh72R" 0}A31232323 0}A i{A28341919i{Ar28 V S 34  T 19 x U 19 rh72V" i{A28341919 i{A A43291414Ar43 V W 29  X 14 x Y 14 UjB72Z" A43291414 A U25 V [ 50  \ Є25 QjB!2^"j  @3@Q3 KA6_  @3 @j KWhichofthefollowing ` bestdescribesyour :a currentroutinephysical Fb activitylevel? 'c 'Strenuous d Moderate :e Mild Ff Sedentary LBg XA6313628XAL6 h 31 :i 36 Fj 28 pf6k" XA6313628 XA PA4195423PAp4 l 19 :m 54 Fn 23 oe6o" PA4195423 PA .#A628569.#Ao6 p 28 :q 56 Fr 9 J@5s" .#A628569 .#A JЄ57 :u 43 Fv Є 0jw" 025 x 50 :y 25 Fz Є QjB!{"j  @4@Q4 B86N|  @4 @j BDoyoucurrently N} smokecigarettes?  ~ Yes N No  Noresponse  p 28 N 72  Є 'p" '15 N 85  Є J@p" @8@22753@8@J22 N 75  3 I?4p" @8@22753 @8@ I14 N 86  Є 0jp" 050 N 50  Є SjjB!p"j  @5@S5 Ij86  @5 @jj IDuringthepastyear,  haveyoueverbeen x admittedtoahospital 2 foranyheartrelated > events? +jj +Yes  No VjExj ܛ@1783ܛ@V17  83 joBx" ܛ@1783 ܛ@j ¨@3169¨@31  69 joBx" ¨@3169 ¨@j ̡@2278̡@22  78 joBx" ̡@2278 ̡@j Y@0100Y@0  100 jjoBx" Y@0100 Y@j @@1000@@100  0#XX2#RHFx" @@1000  @@jj R  4.2.10  Interpretationofdata|(#(#  AThedatareportedinthetableaboverepresentindicatorsofselfreportedhealthstatusand h  behaviorsofpatientswhounderwentsurgeryin1999(i.e.,6to18monthsbeforethestudy T! began).NMMCmedicalstaffwithwhomthesedataweresharedmadethefollowingcomments: @"  c (fx8G  (Axxc ! !" t."   t.~2A3  0    Question1: Thepercentageofrespondentswhoreportedangina withtheslightest $j activityisextremelyhighinGroups1and2andrepresentsanimprobableresult:the %Z  expectedresultwouldbelessthan5%forpatientswhohaveundergonecoronarybypass %F! surgery 9#  2      .Twoconclusionsaresuggestedbytheseresults:(1)theindividualpatientswho &2" reportedexperiencinganginawithordinaryorslightexertionneedtobefollowedupby '# NMMCstaffandshouldvisittheircardiologistimmediately,and(2)thepossibilitythat ( $ thequestionwasmisunderstoodbyrespondents"andthattheresultsarethus )$ inaccurate"shouldbeinvestigated.Itisalsoimportanttostratifythesedatabydiagnosis *% andanalyzeeachstratumseparately.Thisiscrucialfortheinterpretationofangina |+& pectoris;forexample,aftervalvereplacementsurgerychestpainmaybeduetonon  cardiacreasons. t.~݌(#(# Ќ  " t."   t.2A3  0    Question2: Similarinterpretationasforquestion1.Forexample,shortnessofbreath  aftervalvereplacementsurgerymaypersistduetoenlargementoftheheartpriorto v surgery. t.݌b(#(# Ќ  " t."   t.p2A3  0    Question3: Theseresultsareplausible.Patientswilloftenminimizetheirphysical N  activityfollowingsurgeryinorderto sparethemselves. t.p݌> (#(# Ќ  " t."   t.2A3  0    Question4: Thepercentageofrespondentsthathavereportedthattheycurrentlysmoke * | islowerthanexpected;NMMCpersonnelsuspectthatrespondentsmaybeunder  l reportingtheircurrentsmokingstatus. t.݌ X (#(# Ќ  " t."   t.2A3  0    Question5: Theseresultsareplausible. t.݌ D (#(# Ќ   c (fxx   d4.2.20  ImplicationsofresultsfromquestionnaireresponsesforestablishmentofPFUC (#(#   TheprimarygoalofconductingthisprojectwastoestimatethecostofestablishingaPFUCand   totestandcomparedifferentmethodsofcommunicatingwithpatients(i.e.,phonevs.mail).The   resultspresentedaboveintable3shouldbeinterpretedwithcaution!thequestionnairewasnot   pretestedforcomprehensioninactualpatientspriortoitsuse;theresultsthereforemaynot ~ representvalidinformation.However,theseresultsdoprovideimportantguidancetothe j decisionofwhethertoestablishaPFUC"and,ifaPFUCisestablished,totheprocessofits V establishment.Thefollowingpointscanbenoted: B   (Axxc ! !" t."   t.C2A3  0    TheresultshighlighttheimportantresponsibilityofaninstitutionsuchasNMMCto l monitorthehealthstatusoftheirsurgicalpatientsovertime.Theresultsfromquestions1 X and2suggestthatthehealthstatusofindividualswhohavebeenrecentlyoperatedupon D atNMMCmaybeunacceptablylow. t.Cp݌0(#(# Ќ  " t."   t.a2A3  0    TheArmenianpublicisnotaccustomedtofillingoutquestionnaires,eitherina  supervisedorunsupervisedsetting.IfaPFUCisestablished,thequestionnairethatis  usedwillneedtobeextensivelypretestedtoensurethatinformationprovidedbypatients  isasaccurateaspossible.d t.a݌(#(# Ќ  % "% c (fxx   50  Conclusions f (#(#   %BasedontheresultspresentedaboveandconversationswithkeyindividualsatAUAand R! NMMC,conclusionsarepresentedbelowregardingfiveissues: >"   ,X! ! H(h8xc " t."   t.2h  1  .3  0    advantagesanddisadvantagesofestablishingaPFUCatNMMC; t.,݌$h"(#(# Ќ  " t."   t.2h  2  .3  0    anticipatedresponserates; t.1݌%T #(#(# Ќ  " t."   t.2h  3  .3  0    proposedmodelforaPFUC; t.݌%@!$(#(# Ќ  " t."   t.2h  4  .3  0    thecostofestablishingaPFUC;and, t.݌&,"%(#(# Ќ  " t."   t.2h  5  .3  0    implementationscheduleforprojectandmanagementresponsibility. t.݌'#&(#(# Ќ    c (fx8H5.10  0(#(#AdvantagesanddisadvantagesofestablishingaPFUC)$((#(#   TheSteeringCommitteewillusethisreporttoguidetheirdecisionregardingwhetherornotto *%) establishaPFUCatNMMC.Someoftheadvantagesanddisadvantagesofestablishingand v+&* runningaPFUCaresummarizedbelow;thesemayservetoguidetheSCsdeliberations. b,'+  N-(, Advantages   H(h8xc   (Ax8H! !" t."   t.2A3  0    APFUCimprovesthequalityofpostsurgicalcareforindividualpatients. t.݌(#(# Ќ  " t."   t.2A3  0    APFUCfacilitatestheevaluationofsurgicalcare(throughtheanalysisofaggregateddata)  andprovidesakeydatabaseforconductingoutcomesbasedresearchatNMMC. t.݌r(#(# Ќ  " t."   t.2A3  0    APFUCrepresentsakeysteptowardstheestablishmentofNMMCasanationaland ^ regionalleaderincardiaccareandhospitalcare. t..݌J (#(# Ќ  " t."   t.N2A3  0    APFUCservesasamarketingtooltoenhancetheimageofNMMCasacaring,professional, 6  highqualityhealthprovider 9#  3      . t.N{݌" t(#(# Ќ  % n% H(h8x Disadvantages  L    (Ax8H! !" t."   t.W2A3  0    APFUCrequirescapitalandrecurrentexpenses. t.W݌ 8 (#(# Ќ  " t."   t.<2A3  0    Withoutstrongorganizationalcommitmentandtheprovisionofadequateresources,timeand $  effortdevotedtoitsestablishmentandimplementation,aPFUCcandilutethequalityofcare   providedbyotherareasofthehospital. t.<i݌ (#(# Ќ  % 6% H(h8x   5.20  0(#(#Anticipatedresponserates (#(#  tiTheresponseratesthatwerecalculatedinthisstudyrepresenttheresponseofpatientswhodid n notknowthattheywouldbecontactedbyNMMC.Ifsurgicalpatientsweretoldduringtheir Z dischargeprocessthatNMMCwouldcontactthemeverysixortwelvemonthstocheckontheir F healthstatus"andifpatientsprovidedreliablecontactinformation(phonenumberand/or 2 mailingaddress)"itisalmostcertainthattheresponseratesachievedinthisprojectcouldbe p substantiallyincreased.  \ ThelowresponserateofpatientswholiveoutsideofArmenia,coupledwiththehighcostof 4 contactingthem,suggeststhatitmaybeadvisableforaPFUCatNMMCtolimititselfto   followingpatientswholiveinArmenia.Basedondatafrom1999,79%(394/497)ofthe   surgicalpatientsatNMMCliveinArmenia.SincethemajorityofnonArmenianpatientslivein  Georgia,ifitwerefelttobeimportanttoincludeallsurgicalpatientsinthefollowupprogram,it  maybeeffectivetoenterintoanagreementwithaGeorgiancardiaccarefacilitytofollowup ~ GeorgianpatientsusingthePFQ. j Itthusappearsreasonabletoassumethatresponseratescalculatedinthisprojectrepresentthe B! minimumresponseratesthatmightbeachievedifaPFUCweretobeestablishedatNMMC. ."  Thedatasuggestthattheuseofamailbasedfollowupsystem,supplementedbyphonecontact #l! withnonresponderswholiveinYerevan(wheremakingphonecallsisinexpensiveandmost $X" residentshavephones),wouldachievearesponserateofatleast70%,andprobablysignificantly $D # higher. %0!$   5.30  0(#(#ProposedmodelforaPFUC'#&(#(#  tiAmodelfortheestablishmentofaPFUCisproposedbelow.Theprinciplesthatguidethemodel (#' aswellasthekeyelementsofthemodelareoutlined. )$( ЇPrinciples  ! ! (E88H" t."   t.2E  1  .3  0    Thebasicfunctionofthefollowupsystemistoseekinformation(regardingthepatients  currenthealthstatus)andgather(i.e., capture)thatinformation. t.݌(#(# Ќ  " t."   t.X 2E  2  .3  0    Theinitialmodelshouldbemodestinscopeandinexpensive.Itcanbeexpanded,if r necessary,overtime. t.X  ݌^(#(# Ќ  " t."   t. 2E  3  .3  0    Thefollowupsystemshouldbalanceefficiencywithinformationgatheringpower. t.  ݌J (#(# Ќ  " t."   t. 2E  4  .3  0    Themodelshouldencompass(1)thephysicalsystem(i.e.,equipment,etc.)and(2)personnel 6  whoassumeresponsibilityfortheoperationofthesystem. t.  ݌" t(#(# Ќ  " t."   t.,2E  5  .3  0    Thephysicalsystemmustmakefulluseofcomputertechnologyandtheinformationsystems  ` atNMMC.Appropriateuseofthecomputerwillincreaseefficiency:thecomputercan  L  generateperiodiclistingofpatientstobecontactedandautomaticallyprintoutenvelopesand  8  questionnairesthataretobemailed. t.,Y݌$ (#(# Ќ  " t."   t.e2E  6  .3  0    Theindividual(s)responsibleforthePFUCneedstoensurethat(1)patientsarecontacted   (eitherbyphoneorbymail)inatimelymanner,(2)gatherandenterdataand(3)alerta   clinicalspecialistwhenresponsesarereceivedthatmayindicateamedicalproblem. t.e݌ (#(# Ќ  " t."   t.`2E  7  .3  0    Donorsgenerallyprefertofundcapitalexpenses(e.g.,equipment,softwaredevelopment,   etc.)ratherthanrecurrentexpensessuchassalaries.Theproposedmodelshouldbebasedon n theefficientuseofexistingNMMCpersonnelsupplementedbynecessaryhardwareand Z equipmentacquiredthroughoutsidefundingsources.Experimentationintheuseoflocal F volunteersaswellasseekingfundingfromlocalsourcesisproposedbelow. t.`݌2(#(# Ќ  Keyelementsoftheproposedmodel  \ ! ! (U88" t."   t.2U  1  .3  0    PatientstobeincludedinthePFUC :ThePFUCwillincludeallpatientswhoundergo H surgeryatNMMC:adultsandchildren,patientslivinginsideandoutsideofArmenia. 8 FollowingtheestablishmentofthePFUC,allnewsurgicalpatientswillbeincludedinthe $ followupprogram.Patientswhohavealreadybeenoperatedonwillbeaddedtothefollow  updatabaseovertime,beginningwiththosewhoweremostrecentlyoperatedupon. t.5݌(#(# Ќ  " t."   t.2U  2  .3  0    Methodofcontact : t.݌(#(# Ќ  ! !  (Ax8" t."   t.k2A3  0    PatientswholiveinYerevanandhaveamailingaddresscanbecontactedeitherbymail, r byphone,oracombination(e.g.,usingonemethodfirst,andthenattemptingcontactwith ^  nonrespondentsusingthesecondmethod):thechoiceofmethodshasimplicationsfor J! cost,personnel,andcomparabilityofdata.Onepossibleprotocolthatmightbe 6"  establishedisthefollowing.AllpatientslivinginYerevanwillbemaileda "#t! questionnaire.Thosepatientswhodonotrespondtothefirstquestionnairewillbesenta $`" secondquestionnaireonemonthafterthefirstquestionnaire.Patientswhoanswerneither $L # thefirstnorsecondletter,andthosewhodonothaveamailaddress,willbecontactedby %8!$ phone. t.k݌&$"%(#(# Ќ  " t."   t.2A3  0    PatientswholiveoutsideofYerevanwillonlybecontactedbymail,followingthe '#& procedureaboveforYerevanpatients. t.݌(#'(#(# Ќ  % % (U8x ]" t."   t. 2U  3  .3  0    Frequencyofcontact: Patientswillbecontactedeverytwelvemonthsfromthedateoftheir *%) surgery. t.  ݌r+&*(#(# Ќ  " t."   t.!2U  4  .3  0    Contactinformation: ItisvitalforNMMCtohavecomprehensivecontactinformationfor J-(, eachpatientsoastobeabletocontactthemovertime.Eachpatientshospitalrecords  shouldcontainthenames,addresses,andtelephonenumbersofatleastthreeindividualswho  willknowofapatientswhereabouts.Thesecontactindividualsmayincludethepatients  familyandrelativeswhoarenotlivingwiththepatient,closefriends,andworkcolleagues. t.!"݌r(#(# Ќ  " t."   t.$2U  5  .3  0    Patientorientation :Patientswillbeorientedregardingthefollowupsystemduringtheir J   dischargemeetingthatoccursinthehospitalpriortothepatientsdischarge.Patientswill :  begiveninformationregardingthePFUCanditsobjectives,toldtoexpecttoreceivea & x questionnaireintwelvemonths,beaskedtoprovideaprimaryandbackupaddressand  d phonenumberwheretheycanbecontacted,andbeprovidedwithachangeofaddresscard. t.$$݌ P (#(# Ќ  " t."   t.'2U  6  .3  0    Capitalneeds :1computer,1printer,1UPS,shelvesand/orfilingcabinets,adedicated (  telephonewithansweringmachinecapability.  t.''݌ (#(# Ќ  " t."   t.)2U  7  .3  0    Recurrentnonpersonnelneeds: Stationery,toner,paper,envelopes,postagestamps,   questionnaires,room,electricity,telephoneservice.  t.)K)݌ (#(# Ќ  " t."   t.*2U  8  .3  0    Personnelneeds: Tasksthatmustbecarriedoutonanongoingbasisincludethefollowing: t.**݌f(#(# Ќ    (Ax8! !" t."   t.a,2A3  0    preparingandmailingquestionnairepackets t.a,,݌V(#(# Ќ  " t."   t.B-2A3  0    receivingandprocessingquestionnaires,includingmonitoringresponses(andproviding B theappropriatephysicianwithinformationwhenthepatientshealthstatusis . unsatisfactory)andenteringdataintothedatabase t.B-o-݌l(#(# Ќ  " t."   t..2A3  0    callingpatientswholiveinYerevanwhohavenotrespondedtothemailedquestionnaire. X  t..)/݌ (#(# Ќ  ItisestimatedthattheworkloadforNMMCpersonnelforthismodelwouldbe 0 approximatelyonedayperweekin2002andoneandonehalfdaysperweekin2003for  conductofroutinefollowupactivities.Theseactivitiescouldbeconductedbymidlevel  NMMCadministrativesupportstaff.Aseniorclinicianwouldneedtoassumeoverall  managementofthePFUC.Itisanticipatedthatthisdutywouldrequireapproximatelyone  halfdayoftheirtimeperweekonanongoingbasis.Calculationsthatwereusedtoderive z theseestimatesarepresentedinAppendix3. f  % @,% (U8x ++" t."   t.32U  9  .3  0    Fundingsources : t.33݌>" (#(# Ќ    (Ax 8 ! !" t."   t.'52A3  0    Capitalneeds:FundingforcapitalneedsdetailedabovewillbesoughtfromcurrentANP .#! fundingsources. t.'5T5݌$l"(#(# Ќ  " t."   t.Y62A3  0    Recurrentnonpersonnelneeds:Fundingfornonpersonnelrecurrentneedsdetailed %X # aboveforaninitialtwoyearperiodwillbesoughtfromlocalsources,principallywealthy %D!$ individualswhohavebenefittedfrommedicaltreatmentatNMMC. t.Y66݌&0"%(#(# Ќ  " t."   t.$82A3  0    Personnelneeds:NMMCwillassumeresponsibilityformeetingthepersonnelneeds '#& describedabove.Itisproposedthattheseneedsbemetthroughacombinationofexisting ($' NMMCpersonnelandvolunteersfromthecommunityofNMMCpatients. t.$8Q8݌)$((#(# Ќ  % 5% (U8 x 4w4" t. "   t.:2U  10  .3  0    ProductofPFUC :InformationcollectedbythePFUCaboutpatientsisimportantatboththe z+&* individualaswellasaggregatelevels.Individualpatientleveldatadescribingpatients j,'+ currenthealthstatuswillbeimportanttoNMMCcliniciansastheystrivetoprovidethebest V-(, possiblecaretotheirpatientsfollowingtheirsurgery.Aggregatedatawillrepresentarich  sourceofinformationforclinicalresearchandlongtermassessmentofsurgicalinterventions  atNMMC. t.::݌(#(# Ќ  ThePFUCwillneedtodevelopprotocolsfortheroutinesynthesisandgenerationof ^ informationthatisgathered.Attheindividuallevel,itisanticipatedthatlistsofpatients J  whoseresponsestothePFUCquestionnaireindicatethattheyareinneedofcarefroma 6  cardiologistwillbeprovidedtoeachcardiologistatNMMCforactiononaweeklyor " t monthlybasis.Attheaggregatelevel,simplereportsorfigurescanbegeneratedona  ` monthlyorquarterlybasisthatdisplaytrendsinpatienthealthstatus!stratifiedbyvariables  L  suchastypeofsurgicalprocedureorpatientage!overtimefollowingtheirsurgery.  8  =  (Ax 8   (U8 x  @@5.40  0(#(#CostofestablishingandimplementingaPFUCatNMMC (#(#  rACapitalandrecurrentexpensesforthemodelpresentedaboveareoutlinedinthetablebelow.   Costsarepresentedforthefirsttwoandonequarteryearsofoperation(October1,2001   December31,2003)andarebasedontheassumptionsdescribedbelow.Thecostofmailingthe   questionnaireshasbeencalculatedusingaspreadsheet;detailsarepresentedintabularformin n Appendix4. Z Assumptionsofcostestimate 2   (Ax 8 ! !" t."   t.iE2A3  0    ThePFUCwillbeestablishedandoperationalbyOctober1,2001.Forthefirstthreemonths p ofoperation,thePFUCwillonlyenrollnewpatients󀄄i.e.,patientswhohavejustundergone  \ surgerywillbeenrolledatthetimeoftheirdischarge.Oldpatients󀄄i.e.,patientswhohave H undergonesurgeryatNMMCpriortotheestablishmentofthePFUCwillbeenrolledinthe 4 PFUCaccordingtothefollowingschedule:patientswhounderwentsurgeryin1999or2000   willbeenrolledbeginninginJanuary2002,whilepatientswhounderwentsurgerybetween   1993and1998willbeenrolledinthePFUCbeginninginJanuary2003.Patientswillbe  contactedonthe anniversaryoftheirsurgery.Ifthisscheduleisfollowed,allpatientswho  underwentsurgerysincetheestablishmentofcardiacsurgeryservicesatNMMCin1993who ~ canbecontactedwillbeenrolledintothePFUCbytheendof2003. t.iEE݌j(#(# Ќ  " t."   t.gJ2A3  0    Costestimatesbelowarebasedontheestimatedpriceofamailcontact.Thepriceofamail V  contactforeachpatientisdefinedasthecostofamailpacketmultipliedbytheaverage#of B! contactsthatareexpectedtobemadewitheachpatient.Theaveragenumberofcontacts, ."  calculatedfromthepilotstudydocumentedabove,is1.53(75/49)forpatientslivinginthe #l! regionsofArmeniaoutsideofYerevan,1.72(91/52)forpatientslivinginYerevan,and1.8 $X" forpatientslivingoutsideofArmenia. t.gJJ݌$D #(#(# Ќ  " t."   t.M2A3  0    Thecostofamailpacketis130Armeniandrams(AD)forpacketsmailedtopatientsresiding %0!$ inArmeniaand235ADforpatientslivingoutsideofArmenia.Amailpacketconsistsof &"% twoenvelopes(18AD),atwosidedquestionnaire(12drams),andtwostamps(oneforreturn '#& postage)forpacketsmailedtopatientslivinginArmenia(2x50=100AD).Packetsmailed (#' topatientslivingoutsideofArmeniawillonlyhaveoutgoingpostage(205AD). t.MM݌)$((#(# Ќ  " t."   t.OP2A3  0    Personnelcostsarenotincluded,basedontheassumptionsthattaskswilleitherbeperformed z*%) byexistingNMMCpersonnelorbyvolunteers. t.OP|P݌f+&*(#(# Ќ  " t."   t.Q2A3  0    ThetablebelowdisplayscostestimatesfortwoseparatemodelsofthePFUC.Underthefirst R,'+ model,allpatientswillbecontactedbymail.Underthesecondmodel,patientswholivein >-(, Yerevanwillbecontactedbyphone,whilepatientslivingoutsideofYerevanwillbe  contactedbymail. t.QQ݌(#(# Ќ  " t."   t.S2A3  0    Thecostestimatesbelowarebasedonaphasedintwoyearimplementationperiod.Some  patientswillbecontactedtwiceduringthestartupphase(i.e.,patientswhosesurgerywas r performedduring1999,2000and2001)whileotherswillbecontactedonce(patientswhose ^ surgerywasperformedbetween1993and1998orin2002). t.SS݌J (#(# Ќ  " t."   t.U2A3  0    NMMCwasnotabletoprovidethestudyteamwithconsistentdatadifferentiatingthe 6  numberofadultArmenianpatientswhowerefromtheregionsandfromYerevaninagiven " t calendaryear;NMMCcouldonlyprovidedataenumeratingthetotalnumberofadult  ` Armenianpatientswhounderwentsurgeryineachyear.Thestudyteamthereforetookthe  L  computerizedrecordsfromthecalendaryearand, countingbyhand,determinedthat59%  8  oftheArmenianadultpatientswhowereoperatedonin1999werefromYerevan.This $  figurewasusedtoestimatethenumberofadultpatientsfromYerevanandtheregionsforall   otheryears. t.UV݌ (#(# Ќ  " t."   t.Y2A3  0    Thenumberofpatientsforeachpatientcategoryfor2001and2002areprojections,basedon   yeartodatedatathroughMay31,2001. t.YY݌ (#(# Ќ  % HE%  n >@# > >  Table4:EstimatedtotalcostofPFUCfromOctober1,2001toDecember31,2003   y[ *eVfdd,dd ,dd Sdd S dd  dd  dd  dd  dd JVK(#(#,dd ,dd ,dX#,rdX#+  &6%XX 3jjjVdbb 3#XX6%&n]#/XXItem#XX/]#/XX r #XX/)^#/XX YjjVdD24"  0 jjjVd YNumber#XX/^#/XX YjyjdD2r"1 jjVd Y#XX/'_#/XXEstimatedexpense($)#XX/_#/XX Gjj6$r"jyjd G#XX/`#/XX >j-djj > >jVd)dj >Model1 9#  4      Djjd/!"jVd DModel2 Fjj3!"jjd F  Capitaloroneoffexpenses#XX/`#/XX @ #XX/xb#/XX @  @  9jjV&$ r  jj 9+bComputer(PentiumIII;15"monitor;zipdrive) XjVEv  jjV  ?1?X1 yjVf?v  "  ?1 ?jV 0@11000@y1100 sjj`9v   0@1100 0@jV 0@11000@s1100 QjV>9v   0@1100 0@jj QPrinter#XX/b#/XXԀ(HewlettPackardLaserJet2100) XVE "jV  ?1?X1 xVe? ""  ?1 ?V @800@x800 qj^8 " @800 @V @800@q800 PjV=8 " @800 @j PUniversalPowerSource XVE& zjV  ?1?X1 xVe?& z"  ?1 ?V i@200i@x200 qj^8& z i@200 i@V i@200i@q200 PjV=8& z i@200 i@j PTelephonewithansweringmachinecapability XVE~ jV  ?1?X1 xVe?~ "  ?1 ?V b@150b@x150 qj^8~  b@150 b@V b@150b@q150 PjV=8~  b@150 b@j PShelvesand/orfilingcabinets#XX/Ne#/XX XVE* jV  ?1?X1 xVe?* "  ?1 ?V i@200i@x#XX/j#/XX200 qj^8*  i@200 i@V i@200i@q200 PjV=8*  i@200 i@j PSoftwaredevelopment XVE. jV  ?1?X1 xVe?. "  ?1 ?V @o@250@o@x250 qj^8.  @o@250 @o@V @o@250@o@q250 Qjjjj>8. ! @o@250 @o@j Q  Personnelexpenses EjV2$ " jjjj EnCHSRProjectAssistant(@$25perday)#XX/k#/XX#lG;/(#/;lG bVO!2#jV  D@40D@b40#XX/?o#/XX#lG;/o#/;lG Vp@2$"  D@40 D@V @@1000@@#XX/'p#/XX1000#XX/.q#/XX#lG;/ip#/;lG jrB2%3 @@1000 @@V @@1000@@1000#lG;/q#/;lG#XX/tq#/XX [jjjjHB2&3 @@1000 @@j [  Recurrentnonpersonnelexpenses EjV2$6' jjjj E@sroom($100/month) bVO!(jV  ;@27;@b27 Vp@)"  ;@27 ;@V @2700@2700 9#  5      #XX/r#/XX jrB*3 @2700 @V @2700@2700 ZjVGB+3 @2700 @j Zstationery(miscellaneous) XVE:,jV  ?1?X1 xVe?:-"  ?1 ?V i@200i@x200 qj^8:. i@200 i@V i@200i@q200 PjV=8:/ i@200 i@j Ptoner#XX/6u#/XXԀ(4cartridgesperyear@$75percartridge) XVE>0jV  "@9"@X9 xVe?>1"  "@9 "@V @675@x675 qj^8>2 @675 @V @675@q675#XX/x#/XX PjV=8>3 @675 @j Pelectricity($20permonth)#XX/y#/XX YVF4jV  ;@27;@Y27 yVf@5"  ;@27 ;@V @540@y540 qj^86 @540 @V @540@q540 PjV=87 @540 @j Pphone($2permonth)#XX/vz#/XX YVFB8jV  ;@27;@Y27 xVe@B9"  ;@27 ;@V  K@54K@x54 oj\7B:  K@54 K@V  K@54K@o54 OjjV<7B;  K@54 K@j OMailpackets#XX/g|#/XXԀ(includesthepriceofpostagestamps, F< questionnaires,andenvelopes@550drams=$1)#XX/J~#/XX, 9#  6      9jV& ^=jjV 9project F> duration [jVH! ^?"jV 8@25888@[2588 sjj`9F@ 8@2588 8@jV T@1685T@s1685 ZjVG9FA T@1685 T@jj  ZTotalcapitalexpenses BV/!bB jV  B dVQ!bC" V @2700@ d2700 jrBbD3 @2700 @ V @2700@ 2700 cjVPBbE3 @2700 @ j  cTotalpersonnelexpenses BV/! F jV  B dVQ! G" V @@1000@@ d1000 jrB H3 @@1000 @@ V @@1000@@ 1000 cjVPB I3 @@1000 @@ j  cTotalrecurrentnonpersonnelexpenses BV/!"bJ jV  B dVQ!"bK" V @4057@ d4057 jrB"bL3 @4057 @ V @3154@ #XX/~#/XX3154#XX/΅#/XX bjjjVMB"bM3 @3154 @ j bTotalbudget DjjV/!d#NjjjV D fjjVQ!d#O"jjV M@7757M@f7757 jjjrBd#P3 M@7757 M@jjV ƺ@6854ƺ@#XX/#/XX6854#XX/#RHFd#Q3 ƺ@6854  ƺ@jjj R  B% R   5.40  0(#(#ImplementationscheduleforestablishmentofPFUCandmanagementresponsibilities X(#(# #Xo=XXXr#    4XX=XXoItisproposedthataseniorNMMCclinicianwouldhaveoverallresponsibilityforthePFUC.  ThisindividualwouldserveastheChairofacommitteecomprisedofCHSRandNMMC  personnel#Xo=XX4Xš#4XX=XXoԀwhowouldoverseetheproject.TheestablishmentofthePFUCwouldbe p characterizedbythreestages.Inthefirststage,softwarewouldbedeveloped,thefollowup \ questionnairewouldbedesignedandpretested,andthesystemsandproceduresthatwouldguide H  thePFUCwouldbedeveloped.ThisstageoftheprojectwouldbecompletedbySeptember30, 4  2001.Thesecondstagewouldbeathreemonthstartupperiodduringwhichtimeonlynew  t surgicalpatientswouldbeenrolledinthePFUC.Thethirdstagewouldhaveadurationof  ` approximatelytwoyears;duringthistimeallpatientspreviouslyoperatedonatNMMCwouldbe  L  contactedandenrolledintheCenter.NMMCwouldassumeoverallresponsibilityfortheproject  8  throughoutitsduration;CHSRstaffwouldprovidetechnicalassistanceasnecessary. $    #Xo=XX4XĊ#XX=XXo  60  0(#(#RecommendationsandSummary X (#(# ! ! c (fxx  Thisreporthaspresentedafeasibilityandcostanalysisoftheestablishmentofapatientfollow   upcenter(PFUC)atNorkMarashMedicalCenter.TheestablishmentofaPFUCwassuggested   byNMMCleaderstobeanimportantstepinthedevelopmentofNMMCintoaregionalleaderin l thefieldofmedicalcareandclinicalresearch.Theresultspresentedinthisreportsuggestthata X PFUCcouldbeestablishedatNMMCforanacceptablecostiftheworkofestablishingand D maintainingthePFUCiscarriedoutbycurrentNMMCemployeesand/orvolunteers.Thestudy 0 teamrecommendsthataPFUCisestablishedinordertoimprovethemedicalcarethatNMMC p providestoitspatientsandtoincreaseNMMCsabilitytomonitormediumandlongtermtrends \ inthehealthstatusofitspatients.Ifnecessary,thecostofmaintainingthePFUCshouldbe H fundedthroughamodestincreaseinthepriceofsurgery. 4 Thedatapresentedintable3presentacautionarynote.Thesurgicalpatientswhoparticipatedin   thestudyhaveeithermisunderstoodselectedquestionsonthequestionnaireorelseahigh  percentageofthemhaveunacceptablylowhealthstatus.IfaPFUCisestablished,the  questionnaireshouldbecarefullypretestedinordertoensurethatityieldsvaliddata.  |   Appendix1:Questionnairesusedinstudy(English,Armenian,Russian) XO    ?+ 4 <DL!,? T-XXPOSTSURGICALSURVEY #XX-T#T-XX  #XX-Tt#  T-XXLastyearyouhadaheartoperationintheMedicalCenterNork#XX-Tؗ#T-XXԀ#XX-TY#T-XXԀMarash.Wewould   liketoknowyourhealthconditionnow.Pleasefillinthefollowingquestionnaireand  " senditbackinthegivenenvelope.  4   #XX-T#Pleasewriteanyaddresschanges: X    ______________________________________________________________________ .    ______________________________________________________________________   PhoneNumber:(____)____________________________________________________   ЀPleasewriteyourprimarycarephysicianname&addressbelow: 2  Physician:___________________________PhoneNumber:(_____)________________ \ Address:________________________________________________________________ 2 T-XX  #XX-T<#ӀRelative(otherthanspouse)wecouldcontactifunabletoreachyou:  Name:_______________________________PhoneNumber:(_____)________________    Address:________________________________________________________________ r Relationship:_____________________________________________________________ H  PLEASEANSWEREVERYQUESTIONBYFILLINGTHESQUARETHATBEST  DESCRIBESYOURCURRENTCONDITION.PLEASEUSEADARKPENORPENCIL.     B.f:f <DL!XB v  1. : Doyouhaveanginapectoris(chestpain,discomfortortightnessoccasionallyspreadingto x armsorjaw)? N  ,K.4 <DL!f:f XK v   ,E+ 4 <DL!, XE 򀀀#Xo=XXX#X-?X=XXo4A?XX-q#ؾ+A4###Xo=X+ؾB#XX=XXoԀ Never N   򀀀#Xo=XXX#X-?X=XXo4A?XX-q#ؾ+A4,##Xo=X+ؾK#XX=XXo 󀀀Withsevereexertion !     VB.2 W2 <DL!XB  + #Xo=XXX#X-?X=XXo4A?XX-q#ؾ+A4ȣ##Xo=X+ؾ#XX=XXo   Withordinaryexertion #"  {VH+W W <DL!2 W2 XH  + V{H.2 W2 <DL!WW XH   + #Xo=XXXP#X-?X=XXo4A?XX-q#ؾ+A4##Xo=X+ؾϥ#XX=XXo   Withtheslightestactivity }% $   VH+ 4 <DL!2 W2 XH B.f:f <DL!XB v  2. : Underwhatcondition(s)doyouexperienceshortnessofbreath? b'"&  ^K.::4 <DL!f:f XK v  V^H.2 W2 <DL!::4XH   + #Xo=XXX8#X-?X=XXo4A?XX-q#ؾ+A4##Xo=X+ؾ#XX=XXo   Never )b$(  {VH+W W <DL!2 W2 XH  + V{H.2 W2 <DL!WW XH   + #Xo=XXX|#X-?X=XXo4A?XX-q#ؾ+A4˪##Xo=X+ؾ#XX=XXo   Withsevereexertion *1&*  {VH+W W <DL!2 W2 XH  + V{H.2 W2 <DL!WW XH   + #Xo=XXXS#X-?X=XXo4A?XX-q#ؾ+A4##Xo=X+ؾЬ#XX=XXo   Withordinaryexertion ,(,  {VH+W W <DL!2 W2 XH  +  -(-  V{H.2 W2 <DL!WW XH   + #Xo=XXX9#X-?X=XXo4A?XX-q#ؾ+A4##Xo=X+ؾ̮#XX=XXo   Withtheslightestactivity   {VH+W W <DL!2 W2 XH  +  {E+ 4 <DL!WW XEӀ3.Whichofthefollowingbestdescribesyourcurrentroutinephysicalactivity { Ѐlevel? Q     VB.2 W2 <DL!XB  + #Xo=XXX5#X-?X=XXo4A?XX-q#ؾ+A4̱##Xo=X+ؾ#XX=XXo   Strenuous(regularphysicallydemandingactivitieslikemanuallabor,  g  {VH+W W <DL!2 W2 XH  + jogging,heavyhousework)  `  + V{H.2 W2 <DL!WW XH   + #Xo=XXXT#X-?X=XXo4A?XX-q#ؾ+A4(##Xo=X+ؾG#XX=XXo   Moderate(occasionalphysicallydemandingactivities)    {VH+W W <DL!2 W2 XH  + V{H.2 W2 <DL!WW XH   + #Xo=XXX#X-?X=XXo4A?XX-q#ؾ+A4/##Xo=X+ؾN#XX=XXo   Mild(lighthousework,walking,lightgardening)     {VH+W W <DL!2 W2 XH  + V{H.2 W2 <DL!WW XH   + #Xo=XXX#X-?X=XXo4A?XX-q#ؾ+A41##Xo=X+ؾP#XX=XXo   Sedentary,nophysicaleffort V    VH+ 4 <DL!2 W2 XHӀ O   B.f:f <DL!XB v  4. : Doyoucurrentlysmokecigarettes? %y   ^K.::4 <DL!f:f XK v  V^H.2 W2 <DL!::4XH   + #Xo=XXX#X-?X=XXo4A?XX-q#ؾ+A4S##Xo=X+ؾr#XX=XXo   No %  {VH+W W <DL!2 W2 XH  + V{H.2 W2 <DL!WW XH   + #Xo=XXXۻ#X-?X=XXo4A?XX-q#ؾ+A4'##Xo=X+ؾF#XX=XXo   Yes   {VH+W W <DL!2 W2 XH  + {H.f:f <DL!WW XH v  5. : Pleaselistallmedications(includingoverthecounter)youarecurrentlytakingona o regularbasis: E H+f f <DL!f:f XH : _________________________________________________________________ o  : _________________________________________________________________ E  v E+ 4 <DL!ff XEӀ_________________________________________________________________    р6.Duringthepastyear,haveyoubeenadmittedtoahospitalforanyheartrelated s Ѐevents? I   VB.2 W2 <DL!XB   + #Xo=XXX#X-?X=XXo4A?XX-q#ؾ+A4##Xo=X+ؾ#XX=XXo   No I K.2 W2 <DL!2 W2 XK  + #Xo=XXX#X-?X=XXo4A?XX-q #ؾ+A4##Xo=X+ؾ#XX=XXo  Yes B   VH+ 4 <DL!2 W2 XHӀ ;  {?+W W <DL!X?  + Pleaseindicatediagnosis,date,hospital,cityandregion.     + {H.f:f <DL!WW XH v  7. : Personansweringthissurvey: i""  ^K.::4 <DL!f:f XK v  V^H.2 W2 <DL!::4XH   + #Xo=XXXe#X-?X=XXo4A?XX-q#ؾ+A4##Xo=X+ؾ#XX=XXo   Patient $i$ K.2 W2 <DL!2 W2 XK  + #Xo=XXX7#X-?X=XXo4A?XX-q#ؾ+A4##Xo=X+ؾ#XX=XXo   Spouse %b % K.2 W2 <DL!2 W2 XK  + #Xo=XXX#X-?X=XXo4A?XX-q#ؾ+A4L##Xo=X+ؾk#XX=XXo   Doctor(Nurse) &[!& K.2 W2 <DL!2 W2 XK  + #Xo=XXX#X-?X=XXo4A?XX-q#ؾ+A4##Xo=X+ؾ#XX=XXo   Other 'T"'   VH+ 4 <DL!2 W2 XH PLEASESENDQUESTIONNAIREBACKASEARLYASPOSSIBLE.#Xo=XXX*#  (9$)    )%%* =    Xo=X=XXoSX*CX=XXo  Xo=XCXSX*=  ?+ 4 <DL!X?ؾ+=XXoV 5 54T 55 DT#+ؾ =3݌  Ќ  XX#Xo=XXX     #Xo=X=XXo##Xo=X=XXo#       Xo=X=XXoXX=XXo  Xo=XXX  9%( (0 8@H!X9݌̌  Xo=X=XXoXo=X=XXo       Xo=X=XXoXX=XXo  Xo=XXXu  UY*2"BBBBBB dd@U<%( (0 8@H!((0 X<V   T/5 4 T_________________u݌ 4 Ќ  Xo=X=XXoXo=X=XXo       Xo=X=XXoXX=XXo  Xo=XXX  UY*2"BBBBBB dd@RRU?(( (0 8@H!((0 X?T;5  5    TNT;H5D T B   H 44; DH: T4 T T HT@  '4T;0 ( | HT4  TH:*TNH T;T  5D;  44   b 4;00 T 0; D:݌  H Ќ  Xo=X=XXoXo=X=XXo   M+**  dd@n RRM    Xo=X=XXoXX=XXo  Xo=XXX  B%( (0 8@H!((0 XB݌̌  Xo=X=XXoXo=X=XXo       Xo=X=XXoXX=XXo  Xo=XXX}  } ݌̌  Xo=X=XXoXo=X=XXo         Xo=X=XXoXX=XXo  Xo=XXX  <%( (0 8@H!((0 X<*TNH T  @ T; T,  DT, :C݌ :  Ќ  Xo=X=XXoXo=X=XXo     B+( ( 0 8@H!((0 XB X&F%=XXo____________________________________________________________   ____________________________________________________________ L   X#Xo=XF%&#&        Xo=X=XXoXX=XXo    Xo=XXX%  V ,____________________________________________________% __Ԍ G Ќ  Xo=X=XXoXo=X=XXo     'G *TNH T  DT 4 TT; T,4H@  H: g     X 4_________________________V ,_________________ 3  X XV; _________________________________________________   XV5 4H 4H ; 5DT ,  T @ 4 : w     XTT/ TT/VDTT_______________________________ C  X XV ,_____________V; _____________________________ c  X X 4H4T4____________________________________ /  XKH=XXo#Xo=XHK>#& T       ]I4` <hDp x (#((X]    Xo=X=XXo      "9"q  *W=3*.B=W B=WVWA.(3W6.=W  "9  233)q __YԌ #! Ќ    $ ((X, X$    Xo=X=XXo    lG;=XXo'T"#Xo=X;lG]#      Xo=X=XXoXX=XXo  Xo=XXX  1.T 5 T4N D TT (; 40TN4H,50H q% # N   ,44N,:  , 4,N 4HU5, T0 DT):O݌ W&!$ Ќ  Xo=X=XXoXo=X=XXo     " t."  X?+ 4 <DL!((X?ؾ+=XXo t.\2fo3  0 `   #Xo=X+ؾ#  t.\݌#(w#&` (#` (# Ќ  " t."  ?+ 4 <DL!X?ؾ+=XXo t.2fo3  0 `   #Xo=X+ؾ$# 00T T0 DTHT4 t.C݌) %(` (#` (# Ќ  " t."  ?+ 4 <DL!X?ؾ+=XXo t.J2fo3  0 `   #Xo=X+ؾ#4T0T T0 DTHT4 t.J݌M+&*` (#` (# Ќ  " t."  ?+ 4 <DL!X?ؾ+=XXo t.2fo3  0 `   #Xo=X+ؾU#0T T0 DTHT4 t.t݌,6(,` (#` (# Ќ  X  2.T  '4H  H T    DT,EN 4  ; DT:    fcK=XXo#Xo=XKfc]#" t."  ,?+ 4 <DL!X?ؾ+=XXo t.2fo3  0    #Xo=X+ؾ,#Ԁ H H t.K݌,(#(# Ќ  " t."  w ,?+ 4 <DL!X?ؾ+=XXo t.2fo3  0 '   #Xo=X+ؾ# 00T T0 DTHT4 t.݌'(#'(# Ќ  " t."  ?+ 4 <DL!X?ؾ+=XXo t.2fo3  0 '   #Xo=X+ؾC#4T0T T0 DTHT4 t.b݌#'(#'(# Ќ  " t."  ?+ 4 <DL!X?ؾ+=XXo t.v2fo3  0 '   #Xo=X+ؾ#0T T0 DTHT4 t.v݌ 1'(#'(# Ќ   ,wB.T(T 0 8@H!XB ,E+( ( 0 8@H!T(, XE3.  T U  44T ,5T 45H:  % " t."  w ?+ 4 <DL!((X?ؾ+=XXo t.;2fo3  0 '   #Xo=X+ؾ#6TU  44T( T44T0T ,5T,5TD T0T     ,5T) t.;݌ '(#'(# Ќ  " t. "  ?+ 4 <DL!X?ؾ+=XXo t.^2fo3  0 '   #Xo=X+ؾ# T0T DT t.^݌ '(#'(# Ќ  " t. "  ?+ 4 <DL!X?ؾ+=XXo t.2fo3  0 '   #Xo=X+ؾ&#  (  5TD T ,5T,D,   0 DT) t.E݌ '(#'(# Ќ  " t. "  ?+ 4 <DL!X?ؾ+=XXo t.t2fo3  0 '   #Xo=X+ؾ#*TD(4N,  , 5;D;N 5 ) t.t݌ '(#'(# Ќ   Xw?+ T 0 8@H!X?  (4 x c 4.  0,H     XB+( ( 0 8@H!TXB c (fx 4 " t. "   )?+ 4 <DL!((X?ؾ+=XXo t.2fo3  0    #Xo=X+ؾ#ؾ+=XXo  #Xo=X+ؾ(#  `     t.݌m(#(# Ќ  " t. "   t.2fo3  0    ?+ 4 <DL!X?ؾ+=XXo  #Xo=X+ؾ#D t. ݌{(#(# Ќ  ) ?+( ( 0 8@H!X?lG;=XXo#Xo=X;lG# X?+ T 0 8@H!((X?  (4xc 5.  *TNH T 4 DTN DT4,TE 5 0H  !u T 4DH: [  B+ ( 0 8@H!TXB___________________________________________________________ A  X?+( ( 0 8@H!(X?Ӏ___________________________________________________________ ' Ѐ___________________________________________________________     р    X?+ T 0 8@H!((X? 6.  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J  ,B.4 <DL!XB  (4xc / /2   1  .3    A;5W A3W(3 W;3A,WWW;YK !  5,W;,35A, 3W3;; A 3;A3A,37=3WA)? "   ,E+ 4 <DL!4XE X ?+ 4 <DL!X?4A?XX-q#X-?XA4-#  0A $  ! ! c (fx4" t."  ?+ 4 <DL!X?4A?XX- t..2fo3  0    #X-?XA4T/#4W3 W;  t..s/݌% !(#(# Ќ  " t."  ?+ 4 <DL!X?4A?XX- t.C02fo3  0    #X-?XA40#4W3EE W;  t.C00݌&""(#(# Ќ  " t."  ?+ 4 <DL!X?4A?XX- t.12fo3  0    #X-?XA42#4W7 W;  t.122݌'##(#(# Ќ   X?+ 4 <DL!X? ,B.4 <DL!XB  (4xc / /2.  373A3KE; A ;A3E;,; A 3 A 3 ;? )%%  c (fx4" t."  X,E+ 4 <DL!4XE4A?XX- t.52fo3  0    #X-?XA46#Ԁ0; A ;Y t.5:6݌*%&(#(# Ќ  " t."  ?+ 4 <DL!X?4A?XX- t.72fo3  0    #X-?XA4p7#4W3 W;  t.77݌+ ''(#(#   " t."  ?+ 4 <DL!X?4A?XX- t.i82fo3  0    #X-?XA48#4W3EE W;  t.i88݌,(((#(# Ќ  " t."  ?+ 4 <DL!X?4A?XX- t.92fo3  0    #X-?XA49:#Ԁ4W7 W;  t.9X:݌(#(#    ,XB.4 <DL!XB  (4xc 3.  *;Y= ;YW3A; E E53KA?   c (fx4" t."  X, E+ 4 <DL!4XE4A?XX- t. =2fo3  0    #X-?XA4=#@K;Y= ;Y(5W33AK,AKKW3A,AKK  37KKW3A) t. ==݌(#(# Ќ  " t."  ?+ 4 <DL!X?4A?XX- t.4?2fo3  0    #X-?XA4?#V3A;WAKA t.4??݌ (#(# Ќ  " t."  ?+ 4 <DL!X?4A?XX- t.@2fo3  0    #X-?XA4A#, ;Y( K37KKW3A,3.A..) t.@$A݌ (#(# Ќ  " t."  ?+ 4 <DL!X?4A?XX- t.'B2fo3  0    #X-?XA4B#HK;Y(A,5W373A5A  3W) t.'BB݌ (#(# Ќ   X?+ 4 <DL!X? ,B.4 <DL!XB  (4xc 4.  *;WAE?      ,E+ 4 <DL!4XE c (fx4" t."  X ?+ 4 <DL!X?4A?XX- t.F2fo3  0    #X-?XA4F#0A t.FF݌ (#(# Ќ  " t. "  ?+ 4 <DL!X?4A?XX- t.nG2fo3  0    #X-?XA4G# t.nGG݌ (#(# Ќ   X?+ 4 <DL!X? ,B.4 <DL!XB  (4 x c 5.  43;A,5WAA77AE3A 33A3WEE   53 ;A? z    lO?XX-dd  H.4 <DL!4XH ,#X-?XOlJ#_________________________________________________   ,  djdzj ,__________________________________________________ z  ,  ,E+ 4 <DL!, XE ,B.4 <DL!XB 6.  A53 3 W73E A3W53 N 5WW35W37E? 8   ,E+ 4 <DL!4XE c (fx 4 " t. "  X ?+ 4 <DL!X?4A?XX- t.O2fo3  0    #X-?XA4O#0A t.OO݌ `(#(# Ќ  " t. "  ?+ 4 <DL!X?4A?XX- t.nP2fo3  0    #X-?XA4P# t.nPP݌r(#(# Ќ   X?+ 4 <DL!X?Ӏ 0   X?+4 4 <DL!X?43;A,;A W7K7A3K(3, 3W3,W3), n A 3 . X   B0 B  X  ?+ 4 <DL!4X? X________________________________________________ 0   X  B\!!n  X________________________________________________ \!  X ,B.4 <DL!XB  (4 x c 7.  ,3, 53  35W3 0#   ,E+ 4 <DL!4XEhQ?XX-#X-?XQhBV# c (fx 4 " t. "  X ?+ 4 <DL!X?4A?XX- t.W2fo3  0    #X-?XA4W#33 t.WW݌f$ (#(# Ќ  " t. "  ?+ 4 <DL!X?4A?XX- t.iX2fo3  0    #X-?XA4X#;5W; ,;5W;  t.iXX݌x% !(#(# Ќ  " t."  ?+ 4 <DL!X?4A?XX- t.Y2fo3  0    #X-?XA43Z#W(7.AW) t.YRZ݌&!"(#(# Ќ  " t."  ?+ 4 <DL!X?4A?XX- t."[2fo3  0    #X-?XA4[#W;  t."[[݌'"#(#(# Ќ   X?+ 4 <DL!X?43;A,5WA 35W3733EAW. )$%   #Xo=X?XX-#XX=XXo  *%&   Appendix2:CompositionofStudyTeam ]  ]*TVUdddd dd dX#rdX#reVf(#(#,<dd ,<dd +  &6%XX +!bb +CenterforHealthServicesResearch <2$r < RobertMcPherson 9/!0 9 ANPProjectCoordinator 9/!0 9 LusineSaroyan 9/!H  9 Student,CHSRProjectAssistant 9/!H  9 SerinehVoskanian 9/!  9 CHSRIntern 9/!   9 NairaYeritsian 9/! t  9 Student,ANPProjectAssistant 9/! t  9 9/!   9 =3!   =NorkMarashMedicalCenter A7$L  zA HrairHovakimian 9/!b  9 Surgeon >4&b  z  > DavidJanibekyan 9/!0  9 DatabaseAdministrator 9/!0  9 KarineSargsyan 9/!H 9 Cardiologist 9/!H 9 TamaraGalstyan 9/! 9 AdministrativeAssistant 9/! 9 KarineStepanyan 9/! t 9#XX6%& _#&6%XX CoordinatorofInternationalRelations #XX6%&f#&6%XX 9/! t 9 AidaAvagyan 9/! 9#XX6%&f#&6%XX HeadNurseandManagerofAdultClinic #XX6%&Gg#&6%XX 9/!  9 LilitKoshetsyan#XX6%&g#&6%XX 9/!L  9#XX6%&Ch#&6%XX Operator #XX6%&h#1'%L  1  T     &6%XXAppendix3:Calculationsofpersonnelneeds Zi  i#&F%6%&p]#&6%F%& Approximately2,500individualshaveundergonesurgeryatNMMCbetween1993and2000.Itis D anticipatedthat600individualswillundergosurgeryin2001and600moresurgerieswilltakeplacein  2002.Intermsofpersonnelworkload,andassumingthatallindividualscanbecontacted,inthefirst  yearoftheproject(calendaryear2002)approximately1,600patients 9#  7      ׀willbecontactedforfollowup x andinthesecondyearofthisproject(calendaryear2003)3,100patientswillneedtobecontacted.In P  otherwords,allproceduresrelatedtocontactingpatientswillhavetobeperformedapproximately50 ( | timesperweek(30patientsperweekx1.7contactsperpatient)in2002and100timesperweek(60  T patientsperweekx1.7contactsperpatient)in2003.  ,  NMMCpersonnelwillorientsurgicalpatientstothefollowupsurveyduringtheirdischargeprocess    fromthehospital.Thiswilladdanadditionaltasktotheexistingdischargeprocess.However,the `  followupsurveyorientationshouldnottakethephysician/nursewhoconductthedischargeexamvery 8  muchextratimeand#&F%6%&3j#&6%F%&doesnotconstituteanew,distinct,potentiallytimeconsumingtaskinthesameway d  thatmailingPFUCquestionnairesorenteringfollowupdataintothecomputerdoes.Timerequirements <  fororientingpatientstofollowupactivitiesarethusnotincludedinthecalculationsofpersonnelneeds   below.   Thesetimeestimatesaresomewhatliberalinthatsomepatientswillneverbeabletobecontactedand H willthusnotbeincludedinthefollowupdatabase.#XX6%&si#  t *xVdd<dd <<dd <TVU(#(#x,N dd ,Fdd ,9dd ,9dd ,9dd ,9dd +  #Xo=XXXo#XX=XXo 3jjjd88 3/XXTask VjjdA2H"ijjjd VTimerequired H perrepetition  ^ (minutes)#lG;/s#/;lG VjdA2 "mmjjjd V#timesperweek#lG;/t#/;lG Hjjd3$H"jd HTotaltimeperweek H (hours)#lG;/u#/;lG 4*$ ^"jjd 4  P  Njd9 P H@2002H@N2002 jdoB`" H@2002 H@jd L@2003L@2003 jdoB`" L@2003 L@jd H@2002H@2002 jjdoB` " H@2002 H@jd L@2003L@2003 SjDB`!" L@2003 L@jjd SPrepareandmailonequestionnairepacket LB!"j  @2@L2 e[0!#"  @2 @  I@50I@e50 g]1!$"  I@50 I@ Y@100Y@g100 f\2!%" Y@100 Y@  @2@f2 mjZ0!&"  @2 @  @3@m3 PjA?!'"  @3 @j PReceiveandprocessonequestionnaire %y( packet#lG;/Tv#/;lG(enterdataintodatabase,generate#lG;/{#/;lG =) listofpatientswhoseresponsesindicate * theyshouldbecontacted) LBq+j  @5@L5 e[0%y,"  @5 @  5@215@e21T 9#  8      f\1%y-"  5@21 5@  E@42E@f42 e[1%y."  E@42 E@  @2@e2 mjZ0%y/"  @2 @  @3@m#lG;/5|#/;lG3 PjA?%y0"  @3 @j P#lG;/%#/;lGConducttelephonefollowupinterviewwith 1 onepatientwholivesinYerevanwhodid  2 notrespondtothemailedquestionnaire Q!3 (assumethreecallsnecessarytomake "i4 contact)#lG;/#/;lG MC"-5j  $@10$@M10 e[16"  $@10 $@  @5@e5 9#  9      e[07"  @5 @  $@10$@e10 e[18"  $@10 $@  ?1?e#XX/ t#/XX1 mjZ09"  ?1 ?  @2@m#XX/ #/XX2 PjA?:"  @2 @j P#lG;/#/;lGAdministrativetasksinPFUC 8d#1$;j 8 Ad,!1$<"d A Ad,!1$="d A UK!1$>"d  @2@U#XX/#/XX2 mjZ01$?"  @2 @  @3@m3#XX/#/XX RjjA?1$@"  @3 @j RManagementofPFUC#lG;/M#/;lG#XX/k#/XXԀincludinggeneration % A ofanalyses 8jd#M&!Bjj 8 Ajd,!% C"jd A Ajd,!% D"jd A \jK!% E"jd  @5@\#XX/S#/XX5 |jji?% F"  @5 @j  @5@| #lG;/#/;lG5#XX/#OEC% G"  @5  @jj OЇ gi#Xo=XXX#XX=XXo TRP$'3 Letter LandscapeX3' Letter'3 Letter Landscape3'T  Appendix4:0 ` CostofmailpacketsforPFUC ` .` . #Xo=XXXy#*ddN dd N Fdd F9dd 99dd 99dd 99dd 9V..,y , , , , , , , , , , , +  4* 4?+ 4 <DL!X?lG;=XXo5;_;lGFactor 9/! 9 9/!3 9 9/! 9 9/! 9 9/! 9 9/! 9Year#lG;_5;0#5;_;lG#5XbX_5;#5;_bX5X 9/!  9 9/!  9 9/!  9 9/!  9 9/!  9Total#5XbX_5;#5;_bX5X#lG;_5;Ґ#5;_;lG QG,   Q 6,!P3 62002 'P3 '2001 'P3 '2000 'P3 '1999 'P3 '1998 'P3 '1997 'P3 '1996 'P3 '1995 'P3 '1994 'P3 '1993 * P3 * QG,P3   Q#ofcyclesduringproject 6,!l 61 'l3 '2 'l3 '2 'l3 '2 'l3 '1 'l 3 '1 'l!3 '1 'l"3 '1 'l#3 '1 'l$3 '1 * l%3 * QG,l&3   QArmenia 6,!4' 6 '4(3 ' '4)3 ' '4*3 ' '4+3 ' '4,3 ' '4-3 ' '4.3 ' '4/3 ' '403 ' * 413 * QG,423   Qcostofpacket 6,! 3 6130 ' 43 '130 ' 53 '130 ' 63 '130 ' 73 '130 ' 83 '130 ' 93 '130 ' :3 '130 ' ;3 '130 ' <3 '130 *  =3 * QG, >3   Q#adultsYerevan 6,!p ? 6191 'p @3 '191 'p A3 '152 'p B3 '174 'p C3 '201 'p D3 '165 'p E3 '62 'p F3 '37 'p G3 '11 'p H3 '23 * p I3 * QG,p J3   Q#childrenYerevan 6,!8 K 632 '8 L3 '32 '8 M3 '25 '8 N3 '35 '8 O3 '45 '8 P3 '62 '8 Q3 '64 '8 R3 '54 '8 S3 '30 '8 T3 '26 * 8 U3 * QG,8 V3   Q#ofcontactsperpatient 6,! TW 61.72 ' TX3 '1.72 ' TY3 '1.72 ' TZ3 '1.72 ' T[3 '1.72 ' T\3 '1.72 ' T]3 '1.72 ' T^3 '1.72 ' T_3 '1.72 ' T`3 '1.72 *  Ta3 * QG, Tb3   QYerevancosts 6,! c 649862.8 ' d3 '99725.6 ' e3 '79154.4 ' f3 '93464.8 ' g3 '55005.6 ' h3 '50757.2 ' i3 '28173.6 ' j3 '20347.6 ' k3 '9167.6 ' l3 '10956.4 *  m3 *496615.6 QG, n3   Q#adultsArmeniaregions 6,! o 6134 ' p3 '134 ' q3 '106 ' r3 '122 ' s3 '140 ' t3 '114 ' u3 '43 ' v3 '25 ' w3 '8 ' x3 '16 *  y3 * QG, z3   Q#childrenArmeniaregions 6,!V { 663 'V |3 '63 'V }3 '50 'V ~3 '63 'V 3 '71 'V 3 '91 'V 3 '81 'V 3 '65 'V 3 '58 'V 3 '59 * V 3 * QG,V 3   Q#ofcontactsperpatient 6,!r  61.53 'r 3 '1.53 'r 3 '1.53 'r 3 '1.53 'r 3 '1.53 'r 3 '1.53 'r 3 '1.53 'r 3 '1.53 'r 3 '1.53 'r 3 '1.53 * r 3 * QG,r 3   QArmeniaregionscosts 6,!:  639183.3 ': 3 '78366.6 ': 3 '62056.8 ': 3 '73593 ': 3 '41967.9 ': 3 '40774.5 ': 3 '24663.6 ': 3 '17901 ': 3 '13127.4 ': 3 '14917.5 * : 3 *406551.6 QG,: 3   QOutsideofArmenia 6,!  6 ' 3 ' ' 3 ' ' 3 ' ' 3 ' ' 3 ' ' 3 ' ' 3 ' ' 3 ' ' 3 ' *  3 * QG, 3   Qcostofpacket 6,!v  6235 'v 3 '235 'v 3 '235 'v 3 '235 'v 3 '235 'v 3 '235 'v 3 '235 'v 3 '235 'v 3 '235 'v 3 '235 * v 3 * QG,v 3   Q#patientsoutsideArmenia 6,!>  6180 '> 3 '180 '> 3 '143 '> 3 '102 '> 3 '97 '> 3 '88 '> 3 '15 '> 3 '0 '> 3 '0 '> 3 '0 * > 3 * QG,> 3   Q#ofcontactsperpatient 6,!Z 61.8 'Z3 '1.8 'Z3 '1.8 'Z3 '1.8 'Z3 '1.8 'Z3 '1.8 'Z3 '1.8 'Z3 '1.8 'Z3 '1.8 'Z3 '1.8 * Z3 * QG,Z3   QOutsideArmeniacosts 6,!" 676140 '"3 '152280 '"3 '120978 '"3 '86292 '"3 '41031 '"3 '37224 '"3 '6345 '"3 '0 '"3 '0 '"3 '0 * "3 *520290 QG,"3    QTotal(Armenian#5XbX_5;x#5;_bX5Xdrams) 9/!  9165186.1 9/!3 9330372.2 9/!3 9262189.2 9/!3 9253349.8 9/!3 9138004.5 9/!3 9128755.7 9/!3 959182.2 9/!3 938248.6 9/!3 922295 9/!3 925873.9 `V!3 3333a5A 1423457.23333a5A `1423457.2  #lG;_5;ͺ#5;_;lGbXV\3 3333a5A 1423457.2   3333a5A  bNote:allcostsareinArmenian#5XbX_5;f#5;_bX5Xdrams;1USdollar=550Armeniandrams#5XbX_5;~#