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This paper addresses disparities in reperfusion therapy, particularly primary percutaneous coronary interventions (PCI), for elderly patients experiencing acute myocardial infarction (AMI). Despite proven benefits, our center’s data reveals a stark contrast in PCI rates between younger and older patients, leading to significantly higher mortality among the elderly. Rooted in concerns about comorbidities, the reluctance to administer PCI prompts ethical questions and necessitates a critical examination of age-based clinical decision-making. The paper advocates for optimized AMI management protocols, emphasizing an individualized approach and evidence-based guidelines. Recognizing challenges in accurate AMI diagnosis in the elderly, educational initiatives target healthcare professionals and the population, disseminating information about symptoms and treatment benefits. To combat age-related stereotypes, digital tools like virtual consultations and telemedicine enhance accessibility to information. The paper proposes policy initiatives prioritizing clinical condition over age in treatment decisions, ensuring equitable care. In conclusion, urgent action is required to bridge the gap in reperfusion therapy for elderly AMI patients. By fostering inclusivity, implementing education, and advocating policy changes, we aim to ensure every patient, irrespective of age, receives timely and appropriate life-saving interventions.

ImportancePediatric referral centers are increasingly using telemedicine to provide consultations to help care for acutely ill children presenting to rural and community emergency departments (EDs). These pediatric telemedicine consultations may help improve physician decision-making and may reduce the frequency of overtriage and interfacility transfers.ObjectiveTo examine the use of pediatric critical care telemedicine vs telephone consultations associated with risk-adjusted transfer rates of acutely ill children from community and rural EDs.Design, setting, and participantsA cluster-randomized crossover trial was conducted between November 18, 2015, and March 26, 2018. Analyses were conducted from January 19, 2018, to July 23, 2022, 2022. Participants included acutely ill children aged 14 years and younger presenting to a participating ED in 15 rural and community EDs in northern California.InterventionsParticipating EDs were randomized to use telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine:1 telephone) crossover treatment assignment sequences.Main outcomes and measuresIntention-to-treat, treatment-received, and per-protocol analyses were performed to determine the risk of transfer using mixed effects Poisson regression analyses with random intercepts for presenting EDs to account for hospital-level clustering.ResultsA total of 696 children (392 boys [56.3%]; mean [SD] age, 4.2 [4.6] years) were enrolled. Of the 537 children (77.2%) assigned to telemedicine, 251 (46.7%) received the intervention. In the intention-to-treat analysis, patients assigned to the telemedicine arm were less likely to be transferred compared with patients assigned to the telephone arm after adjusting for patient age, severity of illness, and hospital study period (risk rate [RR], 0.93; 95% CI, 0.88-0.99). The adjusted risk of transfer was significantly lower in the telemedicine arm compared with the telephone arm in both the treatment-received analysis (RR, 0.81; 95% CI, 0.71-0.94) and the per-protocol analysis (RR, 0.79; 95% CI, 0.68-0.92).Conclusions and relevanceIn this randomized trial, the use of telemedicine to conduct consultations for acutely ill children in rural and community EDs resulted in less frequent overall interfacility transfers than consultations done by telephone.Trial registrationClinicalTrials.gov Identifier: NCT02877810.

Background: Children with relapsed/refractory cancer have a myriad of palliative care needs. While pediatric oncology clinicians meet many of these needs, studies suggest that these children often have distressing symptoms and that families feel unprepared for their childs end-of-life (EOL). Oncology clinicians cite barriers to pediatric palliative care (PPC) consultation, including concerns that PPC teams will upset families with EOL discussions. This study evaluated topics addressed by PPC teams over the course of their relationship with children who died from cancer. Methods: Retrospective chart review of children who were diagnosed with relapsed/refractory cancer, received PPC consultation at an academic childrens hospital, and died between January 2008 and January 2017. Information was extracted regarding the childs treatment, EOL care, and the content of PPC consultation over the course of the teams relationship with the child/family. Results: Fifty-six children were included in the analysis. The most frequent reasons for the initial consult were pain (n = 31, 55%) and non-pain symptom management (n = 18, 32%). At the initial consult, the PPC team most often discussed symptom management and psychosocial support. Prognosis was not discussed in any initial consult. Over subsequent visits, the PPC team expanded their scope of discussion to include goals of care, advance care planning, and hospice. Discussion: Concerns from oncology clinicians that PPC teams will extend beyond the reasons for initial consult into prognostic/EOL discussions at the first visit may be unfounded. Greater familiarity with PPC team practices may facilitate more timely consultation of PPC and its complementary set of services.

BackgroundSexual and gender minorities (SGM) in the Southern United States face challenges in accessing sexual and gender affirming health care. Alternative care models, like inclusive mobile clinics, help mitigate barriers to care for SGM. There is limited data in the literature on the experience of medical referral processes for SGM individuals accessing services from mobile health clinics.Aims and objectivesThe purpose of this study is to describe the medical referral experiences of SGM clients and their providers at a mobile health clinic in the Southern United States.MethodsWe recruited English-speaking individuals who provided care or received care from the mobile health clinic in South Carolina between June 2019 and August 2020. Participants completed a brief demographic survey and a virtual in-depth, semi-structured individual interview. Data analysis was conducted using an iterative process to generate codes, categories, and themes. Data collection and analysis were terminated once thematic saturation was achieved.ResultsThe findings from this study indicated that the mobile health clinic had an inconsistent referral process that was largely dependent on providers' knowledge. Furthermore, clients and providers expressed individual barriers to the referral process, such as financial barriers, and opportunities to improve the referral process, such as an opt-in follow-up from the mobile clinic and increased mobile clinic resources.ConclusionThe findings in this study underscore the importance of having mobile clinics create a structured referral process that all medical providers are familiar with, and the value of hiring patient navigators that can support and refer clients to care that goes beyond the mobile health clinic setting.

BackgroundRecent endeavors emphasize the importance of understanding early barriers to liver transplantation (LT) by consistently collecting data on patient demographics, socioeconomic factors, and geographic social deprivation indices.MethodsIn this retrospective single-center cohort study of 1657 adults referred for LT evaluation, we assessed the association between community-level vulnerability and individual socioeconomic status measures on the rate of waitlisting and transplantation. Patients' addresses were linked to Social Vulnerability Index (SVI) at the census tract-level to characterize community-level vulnerability. Descriptive statistics were used to describe patient characteristics. Multivariable cause-specific HRs were used to assess the association between community-level vulnerability, individual measures of the socioeconomic status, and LT evaluation outcomes (waitlist and transplantation).ResultsAmong the 1657 patients referred for LT during the study period, 54% were waitlisted and 26% underwent LT. A 0.1 increase in overall SVI correlated with an 8% lower rate of waitlisting (HR 0.92, 95% CI 0.87-0.96, p < 0.001), with socioeconomic status, household characteristics, housing type and transportation, and racial and ethnic minority status domains contributing significantly to this association. Patients residing in more vulnerable communities experienced a 6% lower rate of transplantation (HR 0.94, 95% CI 0.91- 0.98, p = 0.007), with socioeconomic status and household characteristic domain of SVI significantly contributing to this association. At the individual level, both government insurance and employment status were associated with lower rates of waitlisting and transplantation. There was no association with mortality prior to waitlisting or mortality while on the waitlist.ConclusionOur findings indicate that both individual and community measures of the socioeconomic status (overall SVI) are associated with LT evaluation outcomes. Furthermore, we identified individual measures of neighborhood deprivation associated with both waitlisting and transplantation.

BackgroundElectronic consultation (eConsult) programs are crucial components of modern healthcare that facilitate communication between primary care providers (PCPs) and specialists. eConsults between PCPs and specialists. They also provide a unique opportunity to use real-world patient scenarios for reflective learning as part of professional development. However, tools that guide and document learning from eConsults are limited. The purpose of this study was to develop and pilot two eConsult reflective learning tools (RLTs), one for PCPs and one for specialists, for those participating in eConsults.MethodsWe performed a four-phase pragmatic mixed methods study recruiting PCPs and specialists from two public health systems located in two countries: eConsult BASE in Canada and San Francisco Health Network eConsult in the United States. In phase 1, subject matter experts developed preliminary RLTs for PCPs and specialists. During phase 2, a Delphi survey among 20 PCPs and 16 specialists led to consensus on items for each RLT. In phase 3, we conducted cognitive interviews with three PCPs and five specialists as they applied the RLTs on previously completed consults. In phase 4, we piloted the RLTs with eConsult users.ResultsThe RLTs were perceived to elicit critical reflection among participants regarding their knowledge and practice habits and could be used for quality improvement and continuing professional development.ConclusionPCPs and specialists alike perceived that eConsult systems provided opportunities for self-directed learning wherein they were motivated to investigate topics further through the course of eConsult exchanges. We recommend the RLTs be subject to further evaluation through implementation studies at other sites.

BackgroundLos Angeles County Department of Health Services provides medical care to a diverse group of patients residing in underresourced communities. To improve patients' access to addiction medications during the COVID-19 pandemic, Los Angeles County Department of Health Services established a low-barrier telephone service for DHS providers in March 2020, staffed by DATA-2000-waivered providers experienced with prescribing addiction medications. This study describes the patient population and medications prescribed through this service during its initial 12 months.MethodsWe performed a retrospective evaluation of a provider-entered call registry for the telephone consult line. Information was collected between March 31, 2020, and March 30, 2021. The registry includes information related to patient demographics, the reason for visit, and which addiction medications were prescribed. We conducted descriptive statistics in each of these domains.ResultsDuring the study period, 11 providers on the MAT telephone service logged 713 calls. These calls represented a total of 557 unique patients (mean age of 40 years, 75% male, 41% Latino, 49% experiencing homelessness). Most patients either had Medicaid insurance (77%) or were uninsured (20%). The most prescribed addiction medication was buprenorphine-naloxone (90%), followed by nicotine replacement therapy (5.3%), naltrexone (4.2%), and buprenorphine monotherapy (1.8%).ConclusionA telephone addiction medication service is feasible to deliver low-barrier medications to treat addiction in underresourced communities, especially to individuals experiencing homelessness. This can mitigate but does not eliminate disparities in access to addiction medications for communities of color.

BACKGROUND: Alcohol use problems are associated with serious medical, mental health and socio-economic consequences. Yet even when patients are identified in healthcare settings, most do not receive treatment, and use of pharmacotherapy is rare. This study will test the effectiveness of the Alcohol Telemedicine Consult (ATC) Service, a novel, personalized telehealth intervention approach for primary care patients with alcohol use problems. METHODS: This cluster-randomized pragmatic trial, supplemented by qualitative interviews, will include adults with a primary care visit between 9/10/21-3/10/23 from 16 primary care clinics at two large urban medical centers within Kaiser Permanente Northern California, a large, integrated healthcare system. Clinics are randomized to the ATC Service (intervention), including alcohol pharmacotherapy and SBIRT (screening, MI (Motivational Interviewing)-based brief intervention and referral to addiction treatment) delivered by clinical pharmacists, or the Usual Care (UC) arm that provides systematic alcohol SBIRT. Primary outcomes include a comparison of the ATC and UC arms on 1) implementation outcomes (alcohol pharmacotherapy prescription rates, specialty addiction treatment referrals); and 2) patient outcomes (medication fills, addiction treatment initiation, alcohol use, healthcare services utilization) over 1.5 years. A general modeling approach will consider clustering of patients/providers, and a random effects model will account for intra-class correlations across patients within providers and across clinics. Qualitative interviews with providers will examine barriers and facilitators to implementation. DISCUSSION: The ATC study examines the effectiveness of a pharmacist-provided telehealth intervention that combines pharmacotherapy and MI-based consultation. If effective, the ATC study could affect treatment models across the spectrum of alcohol use problems. CLINICAL TRIALS REGISTRATION: This study has been registered on ClinicalTrials.gov (NCT05252221).

BackgroundPrimary care practices are responding to calls to incorporate patients' social risk factors, such as housing, food, and economic insecurity, into clinical care. Healthcare likely relies on the expertise and resources of community-based organizations to improve patients' social conditions, yet little is known about the referral process.ObjectiveTo characterize referrals to community-based organizations by primary care practices.DesignQualitative study using semi-structured interviews with healthcare administrators responsible for social care efforts in their organization.ParticipantsAdministrators at 50 diverse US healthcare organizations with efforts to address patients' social risks.Main measuresApproaches used in primary care to implement social needs referral to community-based organizations.ResultsInterviewed administrators reported that social needs referrals were an essential element in their social care activities. Administrators described the ideal referral programs as placing limited burden on care teams, providing patients with customized referrals, and facilitating closed-loop referrals. We identified three key challenges organizations experience when trying to implement the ideal referrals program: (1) developing and maintaining resources lists; (2) aligning referrals with patient needs; and (3) measuring the efficacy of referrals. Collectively, these challenges led to organizations relying on staff to manually develop and update resource lists and, in most cases, provide patients with generic referrals. Administrators not only hoped that referral platforms may help overcome some of these barriers, but also reported implementation challenges with platforms including inconsistent buy-in and use across staff; integration with electronic health records; management and prioritization of resources; and alignment with other organizations in their market.Conclusion and relevanceReferrals to community-based organizations were used in primary care to improve patients' social conditions, but despite strong motivations, interviewees reported challenges providing tailored and up-to-date information to patients.

BackgroundAdherence to clinical practice guidelines for alcohol and drug screening, brief intervention, and referral to treatment (SBIRT) is often inadequate. Mobile apps developed as clinical translation tools could improve the delivery of high fidelity SBIRT.Methods: This study tested the effectiveness of an SBIRT mobile app conceptually aligned with the Theory of Planned Behavior (TPB) to support SBIRT delivery by health care trainees (nursing, social work, internal medicine, psychiatry, and psychology) working in clinical settings (N = 101). Bivariate analyses examined the rate of SBIRT delivery between trainees assigned to the experimental (app) and control (no app) study conditions; as well as the relationship between TPB-based constructs, intention to deliver SBIRT, and screening rates.Results: No significant differences were identified between the study conditions in SBIRT delivery. Significant correlations were found between intent to screen and TPB variables including attitudes/behavioral beliefs concerning substance use treatment (r = .49, p = .01); confidence in clinical skills (r = .36, p = .01); subjective norms (r = .54, p = .01) and perceived behavioral control over appointment time constraints (r = .42, p = .01). Also significant were correlations between percent of patients screened and confidence (r = .24, p = .05); subjective norms (r = .22, p = .05) and perceived behavioral control (r = .28, p = .01).Conclusions: The negative results of the study condition comparisons indicate the need for further investigation of strategies to optimize mobile app utilization, engagement, and effectiveness as a clinical translation tool. Findings of significant correlations between substance use screening rates and both norms and confidence support the potential value of the TPB model in explaining behavior of health care learners in SBIRT delivery.

We undertook a retrospective observational review of patients referred to a tertiary dermatology department with vulval complaints over 12 months. The most common provisional diagnoses made by the referrer and final dermatology diagnoses were lichen sclerosus (54% and 38%), dermatitis (12.7% and 16.5%) and psoriasis (5.1% and 6.3%). Referrers may benefit from further education about skin diseases of the vulva, topical steroids for vulval complaints and the importance of clinical photography. [ABSTRACT FROM AUTHOR]

Background:The safety of direct-to-consumer telemedicine (TM) is closely related to red flag detection and correct referrals. The adherence to referral criteria from current guidelines is not well quantified. Objective:To analyze the emergency department (ED) referral rate and adherence to referral guidelines in TM encounters of acutely ill patients calling a center that adopts stewardship protocols. Methods: This is a retrospective observational unicentric study, between March 2020 and March 2022, with patients who spontaneously sought direct-to-consumer urgent virtual medical assistance. A video-based teleconsultation was provided immediately after connection. Physicians managed situations according to their clinical judgment. Current guidelines, containing specific guidance for referral if red flags were identified, were available for consultation. Physicians' semiannual performance feedback was carried out. We analyzed the patterns for referral to immediate face-to-face medical evaluation and the agreement degree with the institutional guidelines. Results:A total of 232,197 patients were available, and 14,051 (6.05%) patients were referred to ED. A total of 8,829 (68.4%) referrals were based in specific guidelines according to the International Classification of Diseases hypothesis, and 8,708 (98.6%) were justified according to guidelines. Diarrhea had the highest guidelines' adherence to referral (97.6%), followed by COVID-19 (90%), headache (84.2%), and conjunctivitis (78.8%). Policies did not support 5,222 (31.6%) referrals, though 5,100 (97.6%) of these were justified according to the doctor's clinical judgment. Conclusion:TM doctors' assessment of acutely ill patients has high rates of adherence to guidelines regarding referral. Stewardship protocol adoption provides high rates of red flag description, even in the referral of nonpolicy diseases. [ABSTRACT FROM AUTHOR]

Background: Fibre-optic laryngoscopy is still widely used in daily clinical practice; however, high-definition laryngoscopy using narrow band imaging could be more reliable in characterising pharyngeal and laryngeal lesions. Methods: Endoscopic videos were assessed in a tertiary referral hospital by 12 observers with different levels of clinical experience. Thirty pairs of high-definition laryngoscopy with narrow band imaging and fibre-optic laryngoscopy videos were judged twice, with an interval of two to four weeks, in a random order. Inter- and intra-observer reliability, sensitivity and specificity were calculated in terms of detecting a malignant lesion and a specific histological entity, for beginners, trained observers and experts. Results: Using high-definition laryngoscopy with narrow band imaging, inter-observer reliability for detecting malignant lesions increased from moderate to substantial in trained observers and experts (high-definition laryngoscopy with narrow band imaging κ = 0.66 and κ = 0.77 vs fibre-optic laryngoscopy κ = 0.51 and κ = 0.56, for trained observers and experts respectively) and sensitivity increased by 16 per cent. Conclusion: Inter-observer reliability increased with the level of clinical experience, especially when using high-definition laryngoscopy with narrow band imaging. [ABSTRACT FROM AUTHOR]

Acute liver failure (ALF) is a life-threatening condition characterized by rapid liver function deterioration, necessitating a multidisciplinary approach for optimal perioperative care. This comprehensive review focuses on the critical role of the anaesthesiologist throughout the preoperative, intraoperative, and postoperative phases, addressing the unique challenges posed by ALF. The article begins with an exploration of ALF, underlining the urgency of timely referral to specialized hepatology centres. Liver transplantation emerges as a life-saving intervention, and the complex decision-making process is discussed, emphasizing the need for a multidisciplinary team to assess transplantation candidacy based on established prognostic criteria. In the preoperative phase, the review stresses the importance of early engagement with tertiary liver centres for timely referrals and identifies patients suitable for transplantation. Safe transport protocols are detailed, highlighting the meticulous planning required for the secure transfer of ALF patients between healthcare facilities. The intraoperative management section delves into the anaesthesiologist's key concerns, including neurological status, sepsis, acute kidney injury, body mass index, and preoperative fasting. Hemodynamic stability, fluid management, and coagulation balance during surgery are emphasized, with insights into anaesthesia techniques, vascular access, monitoring, and hemodynamic management tailored to the challenges posed by ALF patients. The postoperative care is thoroughly examined covering neurological, hemodynamic, metabolic, renal, and nutritional aspects. Management of ALF involves multidisciplinary team, including nephrology for continuous renal replacement therapy, transfusion medicine for plasma exchange, critical care for overall patient care, nutritionists for ensuring adequate nutrition, and hepatologists as the primary guides. In conclusion, the review recognizes the anaesthesiologist as a linchpin in the perioperative care of ALF patients. The integration of safe transport protocols and multidisciplinary approach is deemed crucial for navigating complexities of ALF, contributing to improved patient outcomes. This article serves as an invaluable resource for gastroenterologist and intensivists, enhancing their understanding of the anaesthesiologist's indispensable role in the holistic care of ALF patients in an ever-evolving healthcare landscape. [ABSTRACT FROM AUTHOR]

Objective: Hematuria is the most common referral to Urology. Most initial evaluations are normal; however there are few medium- to long-term studies about these patients after they are discharged. Methods: This study was a retrospective observational case-control study. Patients with normal initial investigations in our hematuria clinic (HC) over a 2-year period in 2012-2013 were included. We reviewed the electronic records of patients choosing January 1, 2021, as our reference date providing a median follow-up of 99 months. The primary aim of this study was to assess the missed urothelial malignancy (UM) rate in this cohort and also the UM rate in those re-referred to the HC. Results: The study included 573 patients of whom 24.6% (141/573) were re-referred to urology during the study period. The overall missed UM cancer rate was 0.5% and 0.2% died as a result in this follow-up period. The UM cancer rate in those re-referred was 4.3% and of those re-referred with visible hematuria (VH) the UM cancer rate was 5.7%. No patients re-referred with non-visible VH (NVH) were diagnosed with UM. The only urological death during this time was due to UM. Conclusion: All urological malignancy and mortality remain very low even at mediumto long-term follow-up after an initial normal HC investigation. In this study, no patients with recurrent NVH developed UM; therefore, recurrent NVH is unlikely to need reinvestigation. The risk of UM in those re-referred with VH is low but more substantial and warrants reinvestigation, which should include computed tomography urogram imaging. [ABSTRACT FROM AUTHOR]

Rationale: Timely assessment of a chronic condition is critical to prevent long‐term irreversible consequences. Patients with inflammatory arthritis (IA) symptoms require diagnosis by a rheumatologist and intervention initiation to minimize potential joint damage. With limited rheumatologist capacity, meeting urgency wait time benchmarks can be challenging. We investigate the impact of the maximum wait time guarantee (MWTG) policy and referral volume changes in a rheumatology central intake (CI) system on meeting this challenge. Methods: We applied a system simulation approach to model a high‐volume CI rheumatology clinic. Model parameters were based on the referral and triage data from the CI and clinic appointment data. We compare the wait time performance of the current distribution policy MWTG and when referral volumes change. Results: The MWTG policy ensures 100% of new patients see a rheumatologist within their urgency wait time benchmark. However, the average wait time for new patients increased by 51% (178–269 days). A 10% decrease in referrals resulted in a 76% decrease on average wait times (178–43 days) for new patients and an increase in the number of patients seen by a rheumatologist within 1 year of the initial visit. Conclusion: An MWTG policy can result in intended and unintended consequences—ensuring that all patients meet the wait time benchmarks but increasing wait times overall. Relatively small changes in referral volume significantly impact wait times. These relationships can assist clinic managers and policymakers decide on the best approach to manage referrals for better system performance. [ABSTRACT FROM AUTHOR]

Background and Aims: Rehabilitation targeting patients with cardiac conditions are evident and acknowledged in clinical guidelines. However, participation rates remain suboptimal, with only 50% of all patients with cardiac conditions participating in these programs across Europe. Considering the well‐documented effects of rehabilitation, increasing the referral rate to cardiac rehabilitation would be desirable. This study aimed to evaluate the feasibility of a novel referral strategy that could potentially enhance enrollment in cardiac rehabilitation for patients with heart failure. Methods: This prospective feasibility study incorporating both quantitative and qualitative methods was conducted in an outpatient heart failure clinic and a municipal health care center. 106 patients with heart failure were referred to the heart failure clinic from September 2021 through July 2022. A 15−20 min face‐to‐face physiotherapy consultation was incorporated into usual care, evaluating patients' habitual and actual level of functioning, disability, and physical activity and assessing their potential need and motivation for cardiac rehabilitation. Three predefined quantitative feasibility outcomes: reach, referral rate, and data completeness were assessed. Additionally, semi‐structured interviews explored acceptability among patients and health care professionals at the municipal health care center and the hospital. Finally, the potential effect was assessed based on the enrollment rate. Results: Physiotherapy consultations were offered to 86% of eligible patients; of these, 52% were referred to cardiac rehabilitation. Ninety‐one percent data completeness was achieved. The intervention was well‐accepted by patients and health care professionals. The enrollment rate reached 79%. Conclusion: The novel referral strategy proved feasible concerning reach and data completeness, although the referral rate suggested that further refinements are required before a full‐scale trial. The novel referral strategy was well‐accepted, and enrollment rate approached an acceptable level. [ABSTRACT FROM AUTHOR]

Background: Heparin-induced thrombocytopenia (HIT) is a complication of heparin exposure associated with high risk for morbidity and mortality. Diagnosis and management are complex due to limitations of laboratory testing and the need for nonheparin anticoagulation. Objectives: To increase the delivery of evidence-based care of patients with suspected and confirmed HIT via electronic consultation (e-consult). Methods: We describe the creation and implementation of an e-consult service for patients with concern for HIT at a large academic medical center. Hematology physicians with HIT expertise performed real-time chart review of all patients with a positive screening immunoassay result and provided written recommendations in their electronic health record. Results: Comparison of outcomes for 1 year before and the year after the e-consult service implementation identified improvements in direct thrombin inhibitor stewardship, increased diagnostic accuracy, and decreased length of stay of patients with confirmed HIT. Conclusion: The e-consult platform is a novel method for rapid, targeted consultative guidance, and this single-institution pilot demonstrates its feasibility and effectiveness to improve the care of patients with suspected and confirmed HIT.

ABSTRACT Objective: The quality of care and safety for Telemedicine-discharged patients with suspected respiratory infections are closely related to low rates of prescriptions of unjustified and high-risk medications. This retrospective study aimed to assess adherence to the current COVID-19 guidelines in direct-to-consumer telemedicine encounters at a large center using multidrug stewardship protocols. Methods: A quarterly electronic survey utilizing medical records of individual physician care assessed various quality indicators. Physicians received ongoing adaptive feedback based on personal metrics, with Telemedicine Center recommendations derived from the 2020 Infectious Diseases Society of America guidelines. The study included all consecutive adults with new respiratory symptoms in the last 14 days who sought spontaneous Telemedicine consultations between March 2020 and August 2021. This study analyzed patients with suspected or confirmed COVID-19 and other airway infections. Results: Of the 221,128 evaluated patients, 42,042 (19%) had confirmed COVID-19; 104,021 (47%) were suspected to have COVID-19; and, 75,065 (33%) had other diagnoses. Patients with suspected or confirmed COVID-19 had a mean (+DP) age of 35±12 years. A total of 125,107 (85.65%) patients were managed at home, 2,552 (1.74%) were referred for non-urgent in-office reassessment, and 17,185 (11.7%) were referred to the emergency department for whom there was no further treatment recommendation. The antibiotic rate in confirmed or suspected COVID-19 cases was 0.46%/0.65% and that for non-evidence-based prescriptions was 0.01%/0.005%. Conclusion: Guideline training and Telemedicine consultation feedback may lead to lower antibiotic and antimicrobial prescriptions in suspected and confirmed COVID-19 cases. Multidrug stewardship protocols may improve guideline adherence and reinforce the quality of care and safety in Telemedicine encounters.

BACKGROUND AND OBJECTIVES: The red flags screening purpose is to ensure that signs and symptoms that raise suspicion of serious diseases are being considered during the assessment, assisting physical therapists in their clinical decision process. Brazilian physical therapists are autonomous and can act as first contact professionals in the management of musculoskeletal disorders, therefore, they need to know how to recognize, screen and refer patients with red flags for better therapeutic management. The objectives of this study were to verify whether Brazilian physical therapists can recognize and manage patients who presented red flags, compare professionals’ skills regarding different academic degree levels and clinical experience and identify which factors can influence the results. METHODS: A cross-sectional and quantitative research was conducted, collected from an online questionnaire. The target audience consisted of Brazilian physical therapists who have clinical experience in the management of patients with musculoskeletal disorders. Participants filled demographic data and made clinical decisions based on six clinical cases created by the authors, based on the literature, and reviewed by three experts. Data were analyzed using descriptive statistics, the Chi-square test of independence and logistic regression. RESULTS: The study analyzed 384 answers from Brazilian physical therapists with clinical experience in musculoskeletal conditions. Brazilian physical therapists, in general, have not shown to be able to properly recognize and manage the clinical cases involving red flags, with 23.2% of the sample performing appropriate management for medical conditions, 53.9% for emergency conditions and 61.8% for medical conditions with associated musculoskeletal dysfunction. More years of clinical experience and post-professional education did not positively influence the outcomes. Higher academic degrees (Doctorate) can influence positively on the management of non-emergency medical conditions. CONCLUSION: Brazilian physical therapists who work with patients with musculoskeletal disorders perform poorly in identifying red flags in hypothetical clinical cases.

PurposeEvidence supports the role of prescribed exercise for cancer survivors, yet few are advised to exercise by a healthcare practitioner (HCP). We sought to investigate the gap between HCPs' knowledge and practice from an international perspective.MethodsAn online questionnaire was administered to HCPs working in cancer care between February 2020 and February 2021. The questionnaire assessed knowledge, beliefs, and practices regarding exercise counselling and referral of cancer survivors to exercise programs.ResultsThe questionnaire was completed by 375 participants classified as medical practitioners (42%), nurses (28%), exercise specialists (14%), and non-exercise allied health practitioners (16%). Between 35 and 50% of participants self-reported poor knowledge of when, how, and which cancer survivors to refer to exercise programs or professionals, and how to counsel based on exercise guidelines. Commonly reported barriers to exercise counselling were safety concerns, time constraints, cancer survivors being told to rest by friends and family, and not knowing how to screen people for suitability to exercise (40-48%). Multivariable logistic regression models including age, gender, practitioner group, leisure-time physical activity, and recall of guidelines found significant effects for providing specific exercise advice (χ2(7) = 117.31, p

Purpose of reviewAn expanding body of research documents associations between socioeconomic circumstances and health outcomes, which has led health care institutions to invest in new activities to identify and address patients' social circumstances in the context of care delivery. Despite growing national investment in these "social care" initiatives, the extent to which social care activities are routinely incorporated into care for patients with type II diabetes mellitus (T2D), specifically, is unknown. We conducted a scoping review of existing T2D treatment and management guidelines to explore whether and how these guidelines incorporate recommendations that reflect social care practice categories.Recent findingsWe applied search terms to locate all T2D treatment and management guidelines for adults published in the US from 1977 to 2021. The search captured 158 national guidelines. We subsequently applied the National Academies of Science, Engineering, and Medicine framework to search each guideline for recommendations related to five social care activities: Awareness, Adjustment, Assistance, Advocacy, and Alignment. The majority of guidelines (122; 77%) did not recommend any social care activities. The remainder (36; 23%) referred to one or more social care activities. In the guidelines that referred to at least one type of social care activity, adjustments to medical treatment based on social risk were most common [34/36 (94%)]. Recommended adjustments included decreasing medication costs to accommodate financial strain, changing literacy level or language of handouts, and providing virtual visits to accommodate transportation insecurity. Ensuring that practice guidelines more consistently reflect social care best practices may improve outcomes for patients living with T2D.

BackgroundDuring the COVID-19 pandemic, the use of telemedicine as a way to reduce COVID-19 infections was noted and consequently deregulated. However, the degree of telemedicine regulation varies from country to country, which may alter the widespread use of telemedicine. This study aimed to clarify the telepsychiatry regulations for each collaborating country/region before and during the COVID-19 pandemic.MethodsWe used snowball sampling within a global network of international telepsychiatry experts. Thirty collaborators from 17 different countries/regions responded to a questionnaire on barriers to the use and implementation of telepsychiatric care, including policy factors such as regulations and reimbursement at the end of 2019 and as of May 2020.ResultsThirteen of 17 regions reported a relaxation of regulations due to the pandemic; consequently, all regions surveyed stated that telepsychiatry was now possible within their public healthcare systems. In some regions, restrictions on prescription medications allowed via telepsychiatry were eased, but in 11 of the 17 regions, there were still restrictions on prescribing medications via telepsychiatry. Lower insurance reimbursement amounts for telepsychiatry consultations v. in-person consultations were reevaluated in four regions, and consequently, in 15 regions telepsychiatry services were reimbursed at the same rate (or higher) than in-person consultations during the COVID-19 pandemic.ConclusionsOur results confirm that, due to COVID-19, the majority of countries surveyed are altering telemedicine regulations that had previously restricted the spread of telemedicine. These findings provide information that could guide future policy and regulatory decisions, which facilitate greater scale and spread of telepsychiatry globally.

PurposeTo examine the perspectives of medical and nursing health professionals concerning their roles and responsibilities in providing dietary and exercise advice to cancer survivors, and referrals to allied health professionals.MethodsAn integrative review. PubMed, CINAHL, PsycINFO, Embase, Web of Science databases, and bibliographies of relevant studies were searched from December 2011 to June 2021. All studies were eligible for inclusion. The Mixed-Methods Appraisal Tool (MMAT) was used to critically appraise included studies. Data were extracted and synthesised regarding the perspectives of medical and nursing health professionals on their roles, responsibilities, barriers, and facilitators.ResultsTwenty-one studies involving 3401 medical and nursing health professionals and 264 cancer survivors of diverse cancer types were included. Ten quantitative, nine qualitative, and two mixed-methods studies were eligible. All included studies met at least 80% of the quality criteria in the MMAT. Major findings include the following: (1) medical and nursing health professionals were unclear on their roles in providing dietary and exercise advice to cancer survivors but agreed they play a key role in referrals to dietitians and exercise professionals; (2) most cancer survivors valued the involvement of their general practitioner when receiving dietary and exercise advice.ConclusionAlthough medical and nursing health professionals understand that referrals to allied health professionals form part of their role, there is a lack of clarity regarding their roles to provide dietary and exercise advice to cancer survivors. Future studies should address barriers and facilitators of dietary and exercise advice and referral by medical and nursing health professionals.

BACKGROUND: Previous studies of second opinions in the diagnosis of melanocytic skin lesions have examined blinded second opinions, which do not reflect usual clinical practice. The current study, conducted in the USA, investigated both blinded and nonblinded second opinions for their impact on diagnostic accuracy. METHODS: In total, 100 melanocytic skin biopsy cases, ranging from benign to invasive melanoma, were interpreted by 74 dermatopathologists. Subsequently, 151 dermatopathologists performed nonblinded second and third reviews. We compared the accuracy of single reviewers, second opinions obtained from independent, blinded reviewers and second opinions obtained from sequential, nonblinded reviewers. Accuracy was defined with respect to a consensus reference diagnosis. RESULTS: The mean case-level diagnostic accuracy of single reviewers was 65.3% (95% CI 63.4-67.2%). Second opinions arising from sequential, nonblinded reviewers significantly improved accuracy to 69.9% (95% CI 68.0-71.7%; P

BackgroundBuilding capacity for surgical care in low-and-middle-income countries is essential for the improvement of global health and economic growth. This study assesses in-hospital delays of surgical services at Soroti Regional Referral Hospital (SRRH), a tertiary healthcare facility in Soroti, Uganda.MethodsA prospective general surgical database at SRRH was analyzed. Data on patient demographics, surgical characteristics, delays of care, and adverse clinical outcomes of patients seen between January 2017 and February 2020 were extracted and analyzed. Patient characteristics and surgical outcomes, for those who experienced delays in care, were compared to those who did not.ResultsOf the 1160 general surgery patients, 263 (22.3%) experienced at least one delay of care. Deficits in infrastructure, particularly lacking operating theater space, were the greatest contributor to delays (n = 192, 73.0%), followed by shortage of equipment (n = 52, 19.8%) and personnel (n = 37, 14.1%). Male sex was associated with less delays of care (OR 0.63) while undergoing emergency surgeries (OR 1.65) and abdominal surgeries (OR 1.44) were associated with more frequent delays. Delays were associated with more adverse events (10.3% vs. 5.0%), including death (4.2% vs. 1.6%). Emergency surgery, unclean wounds, and comorbidities were independent risk factors of adverse events.DiscussionPatients at SRRH face significant delays in surgical care from deficits in infrastructure and lack of capacity for emergency surgery. Delays are associated with increased mortality and other adverse events. Investing in solutions to prevent delays is essential to improving surgical care at SRRH.

Purpose This study was performed to examine a comprehensive profile of ophthalmic (OPH) referrals based on diagnosis in a single emergency department (ED) in Korea. Methods We analyzed the clinical profiles of children (< 18 years) who underwent immediate OPH referrals in a tertiary hospital ED, from March 2013 through December 2022. Exclusion criteria were a visit related to procedural complication and a discharge before thorough evaluation. We focused on a diagnosis-based high OPH severity requiring emergency surgery or hospitalization. The profiles were compared according to the severity and age group (0-3, 4-6, 7-12, and 13-17 years). Results A total of 1,939 children consisted of 1,281 (66.1%) with injury and 658 (33.9%) with non-injury. Top 3 injuries were orbital fracture, hyphema, and corneal abrasion, whereas top 3 non-injuries were keratoconjunctivitis, cellulitis, and hordeolum. Children with high OPH severity (54.5%) had significantly lower proportions of girls (26.5% vs. 38.9%), visits on weekend/holiday (34.4% vs. 43.4%), and most non-injury chief complaints, and higher proportions of 13-17 years (41.1% vs. 23.6%), injury (87.7% vs. 40.1%), emergency surgery (4.9% vs. 0.1%), in-ED procedure (9.3% vs. 2.4%), hospitalization (4.0% vs. 0.8%), and most injury mechanisms. With increasing age, high OPH severity, orbital fracture, and hyphema increased in proportions, in contrast to a decreasing tendency in corneal abrasion, keratoconjunctivitis, cellulitis, and hordeolum (all Ps for trend ≤ 0.001). There were 610 (31.5%) children with low OPH severity or no OPH diagnosis. Conclusion True OPH emergencies may be more common in injured, older, or male children. This finding could be useful in focusing on emergencies while diverting less urgent cases to outpatient departments or outside ophthalmology clinics.

Abstract Objectives When referring patients to radiology, it is important that the most appropriate test is chosen to avoid inappropriate imaging that may lead to delayed diagnosis, unnecessary radiation dose, worse patient outcome, and poor patient experience. The current radiology appropriateness guidance standard at our institution is via access to a standalone web-based clinical decision support tool (CDST). A point-of-care (POC) CDST that incorporates guidance directly into the physician workflow was implemented within a subset of head and neck cancer specialist referrers. The purpose of this audit was to evaluate the imaging pathway, pre- and post-implementation to assess changes in referral behavior. Methods CT and MRI neck data were collected retrospectively to examine the relationship between imaging referrals pre- and post-POC CDST implementation. Effective radiation dose and estimated carbon emissions were also compared. Results There was an overall reduction in absolute advanced imaging volume by 8.2%, and a reduction in duplicate CT and MRI imaging by 61%, p

Abstract Background The role of visiting health services has been proven to be effective in promoting the health of older populations. Hence, developing a web system for nurses may help improve the quality of visiting health services for community-dwelling frail older adults. This study was conducted to develop a web application that reflects the needs of visiting nurses. Methods Visiting nurses of public health centers and community centers in South Korea participated in the design and evaluation process. Six nurses took part in the focus group interviews, and 21 visiting nurses and community center managers participated in the satisfaction evaluation. Focus group interviews were conducted to identify the needs of visiting nurses with respect to system function. Based on the findings, a web application that can support the effective delivery of home visiting services in the community was developed. An artificial intelligence (AI) algorithm was also developed to recommend health and welfare services according to each patient’s health status. After development, a structured survey was conducted to evaluate user satisfaction with system features using Kano’s model. Results The new system can be used with mobile devices to increase the mobility of visiting nurses. The system includes 13 features that support the management of patient data and enhance the efficiency of visiting services (e.g., map, navigation, scheduler, protocol archives, professional advice, and online case conferencing). The user satisfaction survey revealed that nurses showed high satisfaction with the system. Among all features, the nurses were most satisfied with the care plan, which included AI-based recommendations for community referral. Conclusions The system developed from the study has attractive features for visiting nurses and supports their essential tasks. The system can help with effective case management for older adults requiring in-home care and reduce nurses' workload. It can also improve communication and networking between healthcare and long-term care institutions.

Background/aimsTo assess the accuracy of real-time telemedicine to diagnose and manage paediatric eye conditions.MethodsDesign: Prospective, non-inferiority study analysing agreement in diagnoses and management plans between telemedicine and in-person examinations. Setting: Paediatric ophthalmology clinic. Population: Children 0-17 years, English-speaking or Spanish-speaking, able to participate in age-appropriate manner, either previously seen by the optometrist and required ophthalmology referral or newly referred from outside source. Procedures: Paediatric optometrist conducted examinations using digital equipment and streamed live to a paediatric ophthalmologist who recorded diagnoses and management plans, then re-examined patients in-person. Subjects were masked to the fact they would see the ophthalmologist in-person, same-day. Main outcome measures: Discrepancy in management plan or diagnosis between telemedicine and in-person examinations. Non-inferiority threshold was

Initial child welfare screening decisions, traditionally made by an individual worker, determine if a family will receive further intervention by child protective services. A multi-disciplinary team (MDT) decision-making approach for child welfare referrals aims to provide a more thorough assessment of needs and strengths and to connect families to appropriate community-based providers. This study examined 159 child welfare referrals handled by MDTs compared to 331 referrals handled via the traditional screening approach. The study used a pseudo randomization procedure to assign referrals to the study conditions: Referrals logged on 2.5 days of the week were assigned to the treatment group; all others were assigned to the comparison group. Referrals handled by an MDT were more than four times as likely as those not handled by an MDT to be referred to community-based organizations (OR = 4.32, p < .001). There were no statistically significant differences in families' engagement with community-based organizations or child welfare outcomes. MDTs are a promising step in the initial process of connecting families to services, although they did not affect this study's longer-term outcomes.

CONTEXT: Palliative care (PC) benefits critically ill patients but remains underutilized. Important to developing interventions to overcome barriers to PC in the ICU and address PC needs of ICU patients is to understand how, when, and for which patients PC is provided in the ICU. OBJECTIVES: Compare characteristics of specialty PC consultations in the ICU to those on medical-surgical wards. METHODS: Retrospective analysis of national Palliative Care Quality Network data for hospitalized patients receiving specialty PC consultation January 1, 2013 to December 31, 2019 in ICU or medical-surgical setting. 98 inpatient PC teams in 16 states contributed data. Measures and outcomes included patient characteristics, consultation features, process metrics and patient outcomes. Mixed effects multivariable logistic regression was used to compare ICU and medical-surgical units. RESULTS: Of 102,597 patients 63,082 were in medical-surgical units and 39,515 ICU. ICU patients were younger and more likely to have non-cancer diagnoses (all P < 0.001). While fewer ICU patients were able to report symptoms, most patients in both groups reported improved symptoms. ICU patients were more likely to have consultation requests for GOC, comfort care, and withdrawal of interventions and less likely for pain and/or symptoms (OR-all P < 0.001). ICU patients were less often discharged alive. CONCLUSION: ICU patients receiving PC consultation are more likely to have non-cancer diagnoses and less likely able to communicate. Although symptom management and GOC are standard parts of ICU care, specialty PC in the ICU is often engaged for these issues and results in improved symptoms, suggesting routine interventions and consultation targeting these needs could improve care.

Objective:To compare clinical recommendations given by psychiatrists and the adherence to these recommendations by primary care physicians (PCP) following consultations conducted by asynchronous telepsychiatry (ATP) and synchronous telepsychiatry (STP).Materials and Methods:ATP and STP consultations were compared using intermediate data from a randomized clinical trial with adult participant enrollment between April 2014 and December 2017. In both study arms, PCPs received written recommendations from the psychiatrist after each encounter. Independent clinicians reviewed PCP documentation to measure adherence to those recommendations in the 6 months following the baseline consultation.Results:Medical records were reviewed for 645 psychiatrists' consult recommendations; 344 from 61 ATP consultations and 301 from 62 STP consultations. Of those recommendations, 191 (56%) and 173 (58%) were rated fully adherent by two independent raters for ATP and STP, respectively. In a multilevel ordinal logistic regression model adjusted for recommendation type and recommended implementation timing, there was no statistically significant difference in adherence to recommendations for ATP compared with STP (adjusted odds ratio = 0.91, 95% confidence interval = 0.51-1.62). The profiles of recommendation type were comparable between ATP and STP.Conclusions:This is the first PCP adherence study comparing two forms of telemedicine. Although we did not find evidence of a difference between ATP and STP; this study supports the feasibility and acceptability of ATP and STP for the provision of collaborative psychiatric care. Clinical Trial Identifier NCT02084979.

Introduction: Autism spectrum disorder (ASD) is a developmental disability that causes significant social, communication and behavioural challenges. The Modified Checklist for Autism in Toddlers (M-CHAT) is a parent-administered screening questionnaire for ASD used at 18 and 36 months of age. This study aimed to determine the outcomes of children who failed M-CHAT screening during routine health screening at maternal and child health clinics in northeast district, Penang and the prevalence of ASD among those with a final diagnosis. Methods: This retrospective cohort study was conducted at 12 maternal and child health clinics. All children who failed M-CHAT screening at 18 and 36 months from January 2017 to December 2021 and received a final diagnosis before 31 March 2022 were recruited. All information required was recorded in a data collection form and analysed using SPSS. Multiple logistic regression was performed to assess the association between the factors and ASD status. Results: Eighty-two children failed M-CHAT screening. Fifty children did not receive a final diagnosis. Among 32 children who received a final diagnosis, 25 were diagnosed with ASD (78.1%). Among the children who underwent M-CHAT screening, the odds of having ASD increased by a factor of 1.2 for every 1-unit increase in age at final diagnosis. Conclusion: In northeast district, Penang, more than half of children who fail M-CHAT screening have no final diagnosis. The specificity of the M-CHAT is 78.1% among children with a final diagnosis of ASD. The age at final diagnosis is positively associated with the diagnosis of ASD. [ABSTRACT FROM AUTHOR]

Background: Lesbian, bisexual+ and queer (LBQ+) cisgender women have considerable unmet mental health needs. The aims of this study were to examine LBQ+ cisgender women's prior engagement with general practitioners (GPs), and how this relationship shaped their mental health service use. Method: Data from 2707 cisgender LBQ+ women were drawn from a national survey of adults who are lesbian, gay, bisexual, trans, intersex, queer or questioning, asexual and other diverse sexuality and gender identities (LGBTIQA+) in Australia. Multivariable logistic regression analyses examined demographic predictors of continuity of care with GPs and GPs' awareness of LBQ+ women's sexual orientation. The relationship between these variables and recent mental health service use was then analysed, comparing LBQ+ women's engagement with services known to be LGBTIQA+ inclusive and those without an inclusive reputation. Results: LBQ+ cisgender women with a regular GP had greater odds of having accessed mental health services in the last 12 months. Two-thirds had a regular GP, with the lowest odds among women aged 18–35 years and highest odds among women with a disability. LBQ+ women who did not believe their regular GP knew of their sexuality had lower odds of having accessed LGBTIQA+ inclusive mental health services. These individuals were typically aged below 25 years, bisexual+ or queer identified, had below undergraduate-level education, earned <$2000 AUD per week, or lived in an outer-suburban or regional area. Conclusion: GPs may be missing opportunities to promote continuity of care through developing trusting relationships with specific sub-populations of LBQ+ women, which in turn appears to sustain inequitable access to mental health care. To offer appropriate care and referrals for this population, GPs should provide safe and inclusive environments to enable comfortable and supportive discussions about sexual orientation when this is relevant to a person's health care. Lesbian, bisexual+ and queer (LBQ+) cisgender women's unmet mental health needs have been extensively documented. We found that continuity of care and disclosure of sexual orientation in general practice may facilitate their access to mental health services in general, as well as LGBTQA+ inclusive mental services; yet GPs appear to be missing opportunities to develop continuity of care and trusting relationships with this population. Improving LGBTQA+ inclusive practice among GPs would ensure more accurate clinical assessment and linkage to appropriate forms of mental health support.. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to evaluate the appropriateness of the emergency referrals made by primary care clinicians and determine the factors contributing to inappropriate referrals. Methods: This crosssectional study utilises referral notes review between October 2019 and March 2020. Patients referred to Khawla Hospital's emergency department by a primary care clinician in Muscat Governorate were randomly selected; their referral notes were reviewed by five family physicians. The appropriateness of the referrals was evaluated according to the primary care referral protocol. Any referral that deviated from the protocol was classified as inappropriate. The prevalence and characteristics of inappropriate referrals were identified, and the factors contributing to inappropriate referral were determined using multivariable logistic regression. Results: In total, 591 referrals were reviewed; 354 (59.9%) of them were classified as inappropriate due to inadequate medical notes (291, 82.2%), lack of provisional diagnosis (176, 49.7%), misdirected to a non-concerned emergency (30, 8.4%) or misclassification of urgency (107 [30.2%] were classified as urgent and 45 [12.7%] as routine). After adjusting for multiple variables, insufficient clinical notes, unavailability of referral guidelines and lack of expertise were found to be strong determinants of inappropriate referral, with an odds ratio of 62.52 (95% confidence interval [CI]: 32.04-121.96), 2.88 (95% CI: 1.40-5.92) and 9.37 (95% CI: 4.09-21.43), respectively. Conclusion: While most of the referrals required emergency management, the majority were inappropriate, mainly due to insufficient clinical documentation. Inadequate clinical notes and lack of national guidelines and expertise were found to be strong predictors of inappropriate emergency referrals. [ABSTRACT FROM AUTHOR]

Objectives: To determine the uptake of the Alfred Health Post‐COVID service among people hospitalised with coronavirus disease 2019 (COVID‐19) or referred by general practitioners; to describe their characteristics and symptoms at eight weeks and the clinical services they required. Study design: Observational cohort study. Setting: Outpatient post‐COVID‐19 follow‐up service in a tertiary Melbourne hospital. Participants: All people admitted to Alfred Health (inpatients, hospital‐in‐the‐home) with COVID‐19, 19 March 2020 – 28 December 2022; people with persistent symptoms referred by general practitioners in the Alfred Health catchment area during 2022. Intervention: Questionnaire‐based symptom assessment eight weeks after onset of COVID‐19. Dyspnoea, fatigue, depression, anxiety, and post‐traumatic stress disorder were assessed with standardised tools, as were health status and health‐related quality of life; return to work or study, weight loss, and altered cognition and memory were also assessed. Screening was followed by physical assessment and management at the service (specialist general medicine review, physiotherapist, allied health assistant, neuropsychologist) and referral to other specialist medical services as required. Main outcome measures: Proportion of eligible people who used the service for follow‐up at eight weeks; proportions of service users who reported symptoms and return to pre‐COVID‐19 employment or study; clinical services required by service users. Results: Of 6712 people invited for screening, 726 completed questionnaires (11%). At least one persistent symptom was reported by 385 of 642 respondents (60% of respondents, 5.7% of invitees), most frequently memory (371 of 656, 57%) or concentration problems (431 of 656, 66%), dyspnoea (197 of 703, 28%), and extreme fatigue (189 of 673, 28%). Sixty‐seven of 453 respondents had not returned to pre‐COVID‐19 work or study (15%). People were referred to a variety of medical and non‐medical services for management, including specialist medical clinics, allied health, and rehabilitation. Among 71 people who also completed questionnaires at twelve months, the proportions who reported fatigue, anxiety, and memory and concentration changes were similar at both assessments. Conclusions: After acute COVID‐19 that required hospital admission or was followed by persistent symptoms in community care, a small proportion of people (5.7%) reported symptoms that required medical and allied health specialist assessment and management. Our findings may assist planning services for people with long COVID. [ABSTRACT FROM AUTHOR]

Chronic Obstructive Pulmonary Disease (COPD) constitutes a major public health problem, and it is anticipated that its prevalence will continue to increase in the future. Its progressive nature requires a continuous and well-coordinated care approach. The follow-up for COPD should primarily focus on disease screening and control, which includes monitoring of pulmonary function, prevention of exacerbations, identification of aggravating factors and comorbidities, as well as ensuring treatment adequacy and adherence. However, existing clinical practice guidelines and consensus documents offer limited recommendations for the follow-up. In this context, we undertake a review of COPD treatment and the continuity of care recommendations endorsed by several scientific societies. Moreover, we underscore the importance of the involvement of nursing and community pharmacy in this process, as well as the utilization of quality indicators in the provision of care for the disease. [ABSTRACT FROM AUTHOR]

Objectives: For older people who worry about their memory, their general practitioner (GP) is often the first healthcare professional they turn to. This study aims to increase knowledge of GPs' daily practice on diagnostic strategies for patients who present themselves with memory complaints and/or worries about dementia for the first time in general practice and to explore associations of patients' characteristics with these strategies. Method: Retrospective observational study using electronic patient records from patients presenting with memory complaints between 2012 and 2019. The patient records are derived from a Dutch primary care registration network. The decision on diagnostic strategy was extracted and categorized as (1) wait and see, (2) diagnostic testing in primary care, or (3) referral. Patient characteristics (gender, age, general practice, level of comorbidities, chronic polypharmacy, and the number of consultations on memory complaints), fear of developing dementia, and information on why the first consultation on memory complaints was scheduled were extracted. Results: A total of 228 patients were included. Most patients were cared for within primary care, either for further primary care diagnostics (56.1%) or because a wait‐and‐see strategy was pursued (14.9%). One‐third (28.9%) of patients were referred. Differences between diagnostic strategies in patient characteristics, fear of developing dementia, or reason for first consultation between these diagnostic strategies were not found, nor were these variables predictive of referral. Conclusion: Most Dutch patients with memory complaints and/or worries about dementia who seek help from their GP for the first time are cared for in the primary care setting for the following 6 months. The lack of association between included patient characteristics and diagnostic strategies highlights the complexity of the decision‐making process on diagnostic testing for dementia in general practice. Key points: Most Dutch patients who seek help for memory complaints from their general practitioner (GP) for the first time are not referred for specialized diagnostic testing, which underlines the crucial and gatekeeper role GPs play in the management and care for this patient group.Previous qualitative research indicates that GPs consider patient characteristics important in decisions on diagnostic trajectories for memory complaints. Retrospective data from the studied electronic patient records, however, indicates that patient characteristics such as age and comorbidity do not differ between diagnostic strategies nor are they predictive for referrals.Further unraveling of the complex decision‐making process for diagnostic testing for dementia is needed to facilitate timely dementia diagnoses. [ABSTRACT FROM AUTHOR]

There is a paucity of literature on the effect of COVID-19 on hospital processes. We hypothesized that COVID-19 was associated with decreased cancer physiatry referrals in 2020. This is a retrospective cohort study of consecutive patients from April to July 2019 and 2020 admitted at an academic quaternary cancer center. The main outcomes were number of hospital admissions, rate, and characteristics of inpatient rehabilitation admissions and change in percentage of physiatry referrals as the primary endpoint. Results showed that in 2019, there were 387 referrals from 10,274 inpatient admissions (3.8%; 95% confidence interval, 2.4–4.2), compared with 337 referrals from 7051 admissions in 2020 (4.8%; 95% confidence interval, 4.3–5.3, P = 0.001). Hematology services referred more patients than neurosurgery in 2020 (20.4% vs. 31.4%; 48.2% vs. 26.5%, P = 0.01). Discharge disposition reflected an increased frequency of return to acute care service in 2020 (10.2% vs. 21.8%, P = 0.03). In conclusion, there was an increase in the rate of physiatry referrals despite a decrease in hospital admissions. There was an increase in referrals by hematology, likely due to emphasis on safe discharge and the populations hospitalized. [ABSTRACT FROM AUTHOR]

Background: Provider and institutional practices have been shown to have a large impact on cancer clinical trial enrollment. Understanding provider perspectives on screening for trial eligibility is necessary to improve enrollment. Methods: A questionnaire about incentives, barriers, process tools, and infrastructure related to opening trials and referring patients to onsite and offsite trials was administered to diverse stakeholders, including professional societies, advocacy organizations, and industry networks. Descriptive statistics were used to summarize findings. Results: Overall, 693 responses were received, primarily from physicians (42.7%) and nurses (35.6%) employed at hospital health systems (43.7%) and academic centers (36.5%). Approximately half (49.2%) screened all patients for onsite clinical trials with screening typically done by manual chart review (81.9%). The greatest incentive reported for offering trials was providing the best treatment options for patients (67.7%). Contracting and paperwork (48.5%) were the greatest barriers to opening more onsite trials. Offsite referrals were rare. Conclusions: Screening for trial eligibility is a largely manual and ad hoc process, with screening and referral to offsite trials occurring infrequently. Administrative and infrastructure barriers commonly prevent sites from opening more onsite trials. These findings suggest that automated trial screening tools built into workflows that screen in a site‐agnostic manner could result in more frequent trial eligibility screening, especially for offsite trials. With recent momentum, in part in response to the COVID‐19 pandemic, to improve clinical trial efficiencies and broaden access and participant diversity, implementing tools to improve screening and referral processes is timely and essential. Plain Language Summary: There are many factors that contribute to low adult enrollment in cancer clinical trials, but previous research has indicated that provider and institutional barriers are the largest contributors to low cancer clinical trial enrollment.In this survey, we sought to gain insight into cancer clinical trial enrollment practices from the perspective of health care providers such as physicians and nurses. We found that only approximately half of respondents indicated their institution systematically screens their patients for clinical trials and this process is manual and time consuming. Furthermore, we found that providers infrequently search for and refer patients to clinical trials at other sites.Creating better screening methods could improve enrollment in clinical trials. A questionnaire was administered to understand provider perspectives and needs related to screening for cancer clinical trial eligibility, including assessment of incentives, barriers, and infrastructure related to opening and referring to trials. Findings from the survey suggest that automated screening tools built into clinical workflows could result in more frequent trial eligibility screening, especially for offsite trials. [ABSTRACT FROM AUTHOR]

Giant cell arteritis (GCA) can lead to severe complications if left untreated. The aim of this study was to describe time from onset of symptoms to diagnosis and treatment in GCA suspected patients in a fast-track clinic (FTC), and secondarily to assess the influence of GCA symptoms on this time. A retrospective cohort consisting of suspected GCA patients who visited the FTC between January 2017 and October 2019 was used. Time between symptom onset, first general practitioner visit, FTC referral, first FTC visit, and treatment initiation was analysed. Furthermore, this was stratified for subtypes of GCA and GCA symptoms. Of 205 patients referred with suspected GCA, 61 patients received a final diagnosis of GCA (GCA+) and 144 patients had no GCA (GCA−). Median time after onset of symptoms to first FTC visit was 31.0 days (IQR 13.0–108.8) in all referred patients. Time between onset of symptoms and first GP visit was 10.5 (4.0–36.3) days, and time between first GP visit and FTC referral was 10.0 (1.0–47.5) days. Patients were generally seen at the FTC within 1 day after referral. For patients with isolated cranial GCA (n = 41), median delay from onset of symptoms to treatment initiation was 21.0 days (11.0–73.5), while this was 57.0 days (33.0–105.0) in patients with extracranial large-vessel involvement (n = 20) (p = 0.02). Our results indicate considerable delay between symptom onset and FTC referral in patients suspected of GCA. Suspected patients were examined and GCA+ patients were treated instantly after referral. Key Points • GCA can cause severe complications with delayed treatment, but non-specific symptoms make diagnosis challenging. • Diagnostic delay still occurs despite introducing a successful fast-track clinic resulting from delay between start of symptoms and FTC referral. • Patients who presented with constitutional symptoms had longer delay than patients who presented with isolated cranial symptoms. [ABSTRACT FROM AUTHOR]

Access to palliative care services is variable, and many inpatients do not receive palliative care. An overview of potential barriers could facilitate the development of strategies to overcome factors that impede access for patients with palliative care needs. To review the current evidence on barriers that impair, delay, or prohibit access to palliative care for adult hospital inpatients. A mixed methods systematic review was conducted using an integrated convergent approach and thematic synthesis (PROSPERO ID: CRD42021279477). The Cochrane Library, MEDLINE, CINAHL, and PsycINFO were searched from 10/2003 to 12/2020. Studies with evidence of barriers for inpatients to access existing palliative care services were eligible and reviewed. After an initial screening of 3,359 records and 555 full-texts, 79 studies were included. Thematic synthesis yielded 149 access-related phenomena in 6 main categories: 1) Sociodemographic characteristics, 2) Health-related characteristics, 3) Individual beliefs and attitudes, 4) Interindividual cooperation and support, 5) Availability and allocation of resources, and 6) Emotional and prognostic challenges. While evidence was inconclusive for most socio-demographic factors, the following barriers emerged: having a noncancer condition or a low symptom burden, the focus on cure in hospitals, nonacceptance of terminal prognosis, negative perceptions of palliative care, misleading communication and conflicting care preferences, lack of resources, poor coordination, insufficient expertise, and clinicians' emotional discomfort and difficult prognostication. Hospital inpatients face multiple barriers to accessing palliative care. Strategies to address these barriers need to take into account their multidimensionality and long-standing persistence. [ABSTRACT FROM AUTHOR]

Mental illness is a risk factor for intentional and unintentional injury and is associated with readmission. The impact of psychiatric consults on length of stay (LOS) of trauma patients is still undergoing study. Trauma registry at Ascension St. Mary's of Saginaw, a community level 2 trauma center, was queried. Further chart review was performed to demographically characterize the control and intervention groups. Univariate and multivariate regression was performed to identify the association between psychiatric consultation and LOS while considering demographic variables and Injury Severity Score. A total of 661 patients were identified with trauma and a documented mental health disorder. 612 did not receive a psychiatric consultation and 49 did. The group without a psychiatric consultation had a mean and median LOS of 6 d and 4 d, respectively, compared to 12 d and 10 d for those with a psychiatric consult (P < 0.0001). Mean ISS scores comparable across all groups. Delirium was associated with the highest LOS with a mean of 17.25 d and a median of 14.5 d. All 11 patients transferred to a psychiatric facility at discharge received a consult for self-harm. Psychiatric consultations were associated with lengthened stay of trauma patients independent of initial injury severity and documented mental health disorders, and more transfers to inpatient psych facilities. This represents an important prognostic factor for a patient's course of care and suggests that trauma physicians should be well-versed at identifying mental health issues which may require early intervention, as well as managing delirium. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to identify the necessity and reasons for patient referral to endodontists among general dentists in Mashhad, Iran, in 2021. Materials and Methods: This research employed a descriptive cross-sectional study design. Two hundred general dentists participated in the survey, answering a questionnaire with confirmed reliability and validity. The questions focused on their reasoning for deciding to perform or not perform root canal treatment, their rationale for referring or not referring patients to endodontists, and the factors influencing these decisions. Data were analyzed using the SPSS-19 software, using Chi-square and Mann–Whitney tests (α = 0.05). Results: Of the respondents, 68% performed root canal therapy routinely, while 8.5% reported never performing root treatment. Men were more likely to perform root canal therapy than women (P < 0.001). Among the dentists who performed root canal therapy, 76.5% considered endodontic referrals necessary, and the number of referrals was higher among female dentists than male dentists (P < 0.001). Overall, the main reasons for referral to endodontists include noncooperation of the patient, open apex, and mouth opening limitations. Fear of losing the patient and the high costs of specialized treatment were the reasons for nonreferral to endodontists. Conclusion: There is a need to eliminate the barriers to endodontic referral among general dentists in Mashhad. Economic issues played a substantial role in dentists' unwillingness to perform root canal therapy and endodontic referral. The study provides insights into the reasons for referral, which can guide the development of strategies to improve endodontic care and patient outcomes. [ABSTRACT FROM AUTHOR]

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Background: The role of visiting health services has been proven to be effective in promoting the health of older populations. Hence, developing a web system for nurses may help improve the quality of visiting health services for community-dwelling frail older adults. This study was conducted to develop a web application that reflects the needs of visiting nurses. Methods: Visiting nurses of public health centers and community centers in South Korea participated in the design and evaluation process. Six nurses took part in the focus group interviews, and 21 visiting nurses and community center managers participated in the satisfaction evaluation. Focus group interviews were conducted to identify the needs of visiting nurses with respect to system function. Based on the findings, a web application that can support the effective delivery of home visiting services in the community was developed. An artificial intelligence (AI) algorithm was also developed to recommend health and welfare services according to each patient's health status. After development, a structured survey was conducted to evaluate user satisfaction with system features using Kano's model. Results: The new system can be used with mobile devices to increase the mobility of visiting nurses. The system includes 13 features that support the management of patient data and enhance the efficiency of visiting services (e.g., map, navigation, scheduler, protocol archives, professional advice, and online case conferencing). The user satisfaction survey revealed that nurses showed high satisfaction with the system. Among all features, the nurses were most satisfied with the care plan, which included AI-based recommendations for community referral. Conclusions: The system developed from the study has attractive features for visiting nurses and supports their essential tasks. The system can help with effective case management for older adults requiring in-home care and reduce nurses' workload. It can also improve communication and networking between healthcare and long-term care institutions. [ABSTRACT FROM AUTHOR]

Background: Primary health care systems have a key role in meeting health needs of community, including function. The aim of this paper is to describe the population involved in the Community Physiotherapist project and their health outcomes over a one-year period. Methods: The Community Physiotherapist is an on-call service which requires a request by general practitioners or medical specialists. Reason for prescription, waiting time for service delivery, diagnostic categories, provided intervention, number of interventions and outcomes were recorded for everyone included in the project. Possible differences in characteristics between individuals referred by medical specialists and general practitioners were also investigated. Results: From January to December 2022, 409 individuals were referred to the Community Physiotherapist pathway. Functional goals were achieved in 79.5% of interventions, without reported adverse events. In most cases physiotherapists provided counselling or caregiver training and 3.3% of individuals needed a full rehabilitation program. The groups of individuals referred by the two types of prescribers showed no significant differences, apart, as expected, from their median age. Conclusions: The introduction of the Community Physiotherapist model within the primary care setting allows to provide appropriate, effective and safe interventions. Sharing the project among all the health professionals helped to support its appropriateness and effectiveness. Results also indicate that a new organizational model, such as the Community Physiotherapist, will take a long time to be implemented. [ABSTRACT FROM AUTHOR]