Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19 disease

Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19.

Evaluating tests for diagnosing COVID-19 in the absence of a reliable reference standard: pitfalls and potential solutions

Background: HIV infections are generally asymptomatic, leading to undetected infections and late-stage diagnoses. There are a lack of acceptable testing strategies for routine opt-out HIV screening. Our aim was to evaluate and compare the diagnostic yield of routine opt-out HIV testing strategies in two out-patient settings in a low HIV prevalence country: The public primary care and specialist out-patient care settingMethods: A cross-sectional study was conducted in a primary care clinic over a four-week period in 2016 to 2017 and in a specialist out-patient clinic over a concurrent 11-month period. Patients were invited to complete a questionnaire assessing demographic characteristics, acceptance of opt-out HIV testing as a policy in all out-patient clinics in Hong Kong and reasons if refusing the HIV test. All respondents were offered an HIV test.Results: This study included 648 and 1,603 patients in the primary care and specialist out-patient clinic, respectively. Test acceptability was 86 and 87% in the primary care and specialist out-patient setting, respectively. Test uptake was 35 and 68% in the primary care and specialist out-patient setting, respectively. No HIV infections were detected.Conclusion: Opt-out HIV testing during routine blood taking in the specialist out-patient setting achieved a high test uptake and acceptability. In contrast, opt-out HIV testing using rapid finger-prick tests in the primary care setting was not effective.

Safe Penicillin Allergy Delabeling in Primary Care: A Systematic Review and Meta-Analysis

Most individual symptoms included in this review have poor diagnostic accuracy. Neither absence nor presence of symptoms are accurate enough to rule in or rule out the disease. The presence of anosmia or ageusia may be useful as a red flag for the presence of COVID-19. The presence of cough also supports further testing. There is currently no evidence to support further testing with PCR in any individuals presenting only with upper respiratory symptoms such as sore throat, coryza or rhinorrhoea. Combinations of symptoms with other readily available information such as contact or travel history, or the local recent case detection rate may prove more useful and should be further investigated in an unselected population presenting to primary care or hospital outpatient settings. The diagnostic accuracy of symptoms for COVID-19 is moderate to low and any testing strategy using symptoms as selection mechanism will result in both large numbers of missed cases and large numbers of people requiring testing. Which one of these is minimised, is determined by the goal of COVID-19 testing strategies, that is, controlling the epidemic by isolating every possible case versus identifying those with clinically important disease so that they can be monitored or treated to optimise their prognosis. The former will require a testing strategy that uses very few symptoms as entry criterion for testing, the latter could focus on more specific symptoms such as fever and anosmia.

HighlightsWhat are the main findings?Pediatric healthcare professionals show a high interest in developing virtual visits (VVs), as an alternative and complementary option to in-person care, and they considered them especially useful for follow-up appointments, specialist consultations, and care of older children and adolescents.Primary care pediatricians have fewer technical resources and lower interest, while hospital-based pediatricians report better equipment and greater interest in VVs. In both settings, interest decreases as professionals’ age increases, and older clinicians report more perceived barriers, especially low confidence in handling computers or digital tools.What are the implications of the main findings?Successful implementation requires improving technical infrastructures and providing specific training and preparation, especially for older professionals.Primary care professionals will additionally require stronger technical support to ensure equitable and effective implementation.Background/Objectives: This study explores the perceptions, experiences, and expectations of pediatric healthcare professionals regarding the implementation of virtual visits (VVs) in routine pediatric practice. Methods: Using the Consolidated Framework for Implementation Research (CFIR) to analyze individual, organizational, and contextual factors influencing the adoption of pediatric virtual visits, we conducted a descriptive cross-sectional survey distributed nationwide among pediatricians, pediatric nurses, and residents. Results: A total of 308 Spanish healthcare professionals correctly completed the REDCap survey and were included in the analysis. The mean age was 44.3 years, and respondents represented both hospital-based (55.8%) and primary care professionals (44.2%). Overall, 74.8% had previous experience with telephone consultations, while only 11% had performed virtual visits. Most professionals believed VVs could be useful in primary care (81.3%) and hospital out-patient settings (73.9%), especially for follow-up appointments, communication of test results, and chronic-care monitoring. VVs were perceived as more appropriate for older children and adolescents than for infants. Major concerns included poor internet connection (52.6%), and data security (37.4%); however, a particularly relevant finding was the low confidence in using digital tools, particularly among older professionals. Comparative analyses by age and workplace setting identified differences in interest, perceived barriers, and access to technical resources. Hospital-based clinicians reported greater interest in adopting VVs and better access to technological resources compared with primary care professionals. The professionals’ age was inversely associated with interest in VVs. Notably, 72.6% of respondents expressed interest in receiving specific VV training, and nearly 90% believed virtual visits should be offered in their workplace. Conclusions: These findings show a high overall acceptance of VVs but also underline persistent barriers related to infrastructure, digital literacy, and clinical applicability in younger children. Addressing these obstacles through training, improved equipment, and clear clinical protocols will be essential for the successful implementation of pediatric VV programs.

BackgroundDiabetes mellitus (DM) is a rapidly increasing serious health problem that affects the population all over the world. The increasing prevalence of DM in Saudi Arabia is reflected in our hospital admissions as well. This study aimed to assess the proportion of DM (including type 1 and type 2 diabetes) among hospitalized patients and the reasons for admissions to the medical unit at King Abdul-Aziz University Hospital (KAUH) in Jeddah, Saudi Arabia.MethodsWe conducted a hospital record-based cross-sectional study at KAUH from January to April 2021. The study included all adult patients admitted to the internal medicine wards and isolation unit but excluded patients in the coronary care unit and those with gestational diabetes. We reviewed the medical records to collect demographic data, causes of admission, laboratory results, and outcomes.ResultsAmong the hospitalized patients, 49.9% had DM. The most common associated risk factors and causes of admission among patients with DM were hypertension (HTN; 73.2%) and dyslipidemia (43.1%). Other less common reasons for admission were heart failure (20.6%), coronavirus disease-2019 (COVID-19; 17.8%), chronic kidney disease (CKD; 14.5%), pneumonia (12.3%), and stroke (10%). Dyslipidemia, HTN, CKD, diabetic ketoacidosis, heart failure, and need for intensive care unit (ICU) admission were significantly higher in diabetic patients as compared to patients without diabetes. HTN, dyslipidemia, CKD, heart failure, stroke, acute abdomen, and malignancy were significantly higher in patients with type 2 diabetes. Among diabetic patients, those with non-Saudi nationality, low hemoglobin level, dyslipidemia, pneumonia, sepsis, and requiring ICU admission had a greater risk of death.ConclusionsThe high burden of DM on the secondary healthcare level in Saudi Arabia highlights the need for effective diabetes prevention and treatment strategies in primary care and hospital outpatient settings. Such measures would help reduce the hospitalization rate and ease the healthcare system’s burden.

BackgroundTo measure and compare the extent to which shared a decision making (SDM) process is implemented both in psychiatric outpatient clinical encounters and in the primary care setting from the patient’s perspective.MethodsA total of 1,477 patients recruited from the Canary Islands Health Service mental health and primary care departments were invited to complete the nine-item Shared Decision Making Questionnaire (SDM-Q-9) immediately after their consultation. MANCOVA, Student’s t-test, and Pearson correlations were used to assess the relationship and differences between SDM-Q-9 scores in patient samples.ResultsNo differences were found in SDM-Q-9 total scores between the two patient samples, but there were relevant differences when item by item analysis was applied; differences were observed according to the different steps of the SDM process. SDM is present to a very limited extent in the routine psychiatric setting compared to primary care. Patients’ age, education, type of appointment, and treatment decision all play a specific role in predicting SDM.ConclusionThe study provides evidence that SDM is a complex process that needs to be analyzed according to its different steps. SDM patterns were different in the primary care and psychiatric outpatient care settings and reflect quite a different perspective of the decision making process.

To characterise post-stroke depression (PSD) diagnostic and treatment patterns in an outpatient primary care setting, including timing, screening methods, therapeutic interventions and associations with mortality. A retrospective cohort study. Maccabi Healthcare Services, the second largest Healthcare Maintenance Organisation in Israel, covering more than 2.7 million citizens between 2016 and 2022. Participants were adult patients with a new stroke diagnosis between 2016 and 2022 and a subsequent diagnosis of depression according to International Classification of Diseases clinical criteria or antidepressant medication initiation. Patients with a diagnosis of depression or antidepressant treatment prior to stroke were excluded from the study. Primary outcomes included PSD diagnosis rates, time to diagnosis and treatment, use of screening questionnaires, specialty of the physician making the diagnosis and all-cause mortality. Secondary outcomes included referral rates to mental health services, rehabilitation participation and its impact on mortality. Among 11 499 patients, PSD occurred in 4620 (40.2%) patients. Primary care physicians diagnosed 53.1% of cases based on clinical assessment; only 4.5% of patients underwent Patient Health Questionnaire-2 screening. Most diagnoses occurred in the first year (53.4%). Antidepressants, predominantly selective serotonin reuptake inhibitors (58.3%), were initiated within 30 days in 65.1% of diagnosed patients. Patients with PSD demonstrated higher rehabilitation participation (69.5% vs 48.5%, p<0.001) and paradoxically lower mortality rates (22.1% vs 27.9%, p<0.001). Patients without PSD were older with a greater comorbidity burden. Cox regression identified physiotherapy visits (HR=0.625, p<0.001) and mental health consultations (HR=0.642, p<0.001) as protective factors. In this cohort, in an outpatient primary care setting, primary care physicians diagnosed the majority of PSD cases, predominantly relying on clinical criteria, without using screening tools. The majority of PSD diagnoses occurred during the first year after stroke (53.1%), suggesting that repeated evaluation might be appropriate during this follow-up period. Early antidepressant treatment and enhanced rehabilitation engagement may positively influence mortality outcomes in patients with PSD. Low utilisation of standard screening tools and mental health referrals represents an area for potential improvement in PSD management.

Objectives: Anterior cruciate ligament reconstruction (ACLR) is one of the most performed orthopedic procedures in the United States and the volume and cost are increasing annually. Patients are increasingly expected to share a larger economic burden with out-of-pocket expenditures. Recently, there has been a shift to perform more ACLR surgeries outside of the hospital setting to reduce costs. The purpose of this project is to understand the differences in costs between ACLR performed in ambulatory surgery center (ASC) versus outpatient hospital settings and if or how this affects the patient’s out-of-pocket expenditure. Methods: We identified patients who had undergone outpatient arthroscopic ACLR in the United States (U.S.) using the IBM MarketScan Commercial Claims and Encounters Database. The database was chosen for its large, national sample of privately insured patients. Patients who had Current Procedural Terminology (CPT) code 29888 between April 1, 2013 and June 30, 2017 were included. Revision ACL procedures and procedures with a concomitant microfracture, medial collateral ligament, lateral collateral ligament, or posterior cruciate ligament repair or reconstruction (CPT: 29879, 27405, 27409, 27427, 29889) were excluded. Day-of-surgery expenditure was identified by summing all claims billed with an “immediate-procedure-related code” in a 3-day window surrounding the date of the procedure (Procedure Date ± 1 Day). The day-of-surgery expenditure was broken down into implant, anesthesia services, regional anesthesia, operating room facility, surgical team, and other expenditures. Regional anesthesia is not included in anesthesia services expenditure. Median and interquartile range were calculated for each variable. The breakdown of day-of-surgery expenditure and patient out-of-pocket expenditure between the outpatient hospital and ASC settings were compared using two-tailed Mann Whitney U Tests. Spearman Rank Order Correlation was done for all variables to test for association between expenditure and year to determine trends over time. All values were inflation adjusted to 2017 dollars. Results: A total of 34,862 patients were identified. Our results indicated that ACLR performed in the outpatient hospital setting result in 60% greater day-of-surgery expenditure (p &lt; 0.001) than in the ASC setting. In the outpatient hospital setting, operating room facility cost was 36% greater (p &lt;0.001), anesthesia services was 7.1% greater (p&lt;0.001), implant was 28% greater (p&lt;0.001), but regional anesthesia was 22% lower (p&lt;0.001). Additionally, for ACLRs performed in the outpatient hospital setting, Spearman coefficients demonstrated that expenditure for anesthesia services decreased (rho = -0.037, p &lt; 0.001) and operating room facility cost increased (rho = 0.058, p &lt; 0.001) over our study period. For ACLRs performed in the ASC setting, expenditure for regional anesthesia decreased (rho = -0.039, p &lt; 0.001). Surgical team reimbursement decreased over time for ACLRs performed in both the ASC (rho = -0.156, p &lt; 0.001) and outpatient hospital (rho = -0.11, p &lt; 0.001) settings. Lastly, total patient out-of-pocket expenditure for ACLRs performed in the outpatient hospital setting vs. ASC setting was very similar though statistically different (p = 0.02, &lt;$10 difference). Conclusions: ACLR performed in an ASC setting results in significant cost savings for payers with no change in surgeon reimbursement. Most of the cost savings came from operating room facility expenditure. For patients, there is almost no financial difference regarding where the ACLR was performed, with the difference in patient out-of-pocket expenditure being less than $10. For the surgeon, surgical team reimbursements are essentially neutral between the ASC and outpatient hospital settings. However, the overall trend in surgical team reimbursement is downwards in both the ASC and outpatient hospital settings. For the two biggest stakeholders in the surgery (surgeon and patient), there are no financial incentives to do an ACLR at an outpatient hospital over an ASC. For a healthcare system, especially under a population health perspective, the incentive to perform ACLRs at an ASC is significant. The cost savings come from every breakdown category, with implant and operating room facility costs being significantly decreased in the ASC setting. Decreased implant costs were likely due to preferred vendor contracts for ASCs. The cost savings achieved per ACLR in an ASC vs. an outpatient hospital equals almost $6000. With nearly 100,000 ACLRs performed per year, the U.S. healthcare system could save a projected $600 million per year on ACLRs alone when the surgery is performed in an ASC. Thus, our study shows that there is a clear financial advantage to the healthcare system for ACLRs being done at ASCs, although the patient does not realize these cost savings. [Figure: see text][Table: see text][Table: see text][Table: see text]

Best practice guidelines for asthma management recommend education and spirometry at specific intervals. A written asthma action plan with education and spirometry is ordered at the discretion of physicians at our institution. An initial chart review revealed that asthma education and spirometry were not consistently ordered in the pediatric primary care clinics. This quality improvement study aimed to increase frequency of spirometry and asthma education in children with asthma seen in pediatric primary care through use of a respiratory therapist (RT)-driven protocol. The protocol established that spirometry and education would be done annually for children ≥ 6 y of age with intermittent asthma and every 6 months for persistent asthma. RTs identified eligible subjects and placed the electronic medical record orders before the clinic visit. Physicians were invited to complete a questionnaire before and after protocol implementation to assess barriers and protocol satisfaction. Nine hundred and thirty-two children were included. Prior to protocol implementation, spirometry and education were completed in 64.9% and 62.6% of eligible children, respectively. Following protocol implementation, spirometry and education were significantly increased to 92.7% (P < .001) and 88.5% (P < .001), respectively. Physicians identified interruption in clinic flow as the primary barrier for ordering spirometry and were satisfied with the protocol. Physicians stated that communication with RT improved through use of this protocol. Implementation of an RT-driven protocol in an out-patient pediatric primary care setting significantly increased utilization of spirometry and education for children with asthma. RTs working in the pediatric out-patient primary care setting played a vital role in achieving best practices for asthma management. The implementation of the protocol enhanced interdisciplinary communication.

BackgroundThe overuse and abuse of antibiotics is a major risk factor for antibiotic resistance in primary care settings of China. In this study, the effectiveness of an automatically-presented, privacy-protecting, computer information technology (IT)-based antibiotic feedback intervention will be evaluated to determine whether it can reduce antibiotic prescribing rates and unreasonable prescribing behaviours.MethodsWe will pilot and develop a cluster-randomised, open controlled, crossover, superiority trial. A total of 320 outpatient physicians in 6 counties of Guizhou province who met the standard will be randomly divided into intervention group and control group with a primary care hospital being the unit of cluster allocation. In the intervention group, the three components of the feedback intervention included: 1. Artificial intelligence (AI)-based real-time warnings of improper antibiotic use; 2. Pop-up windows of antibiotic prescription rate ranking; 3. Distribution of educational manuals. In the control group, no form of intervention will be provided. The trial will last for 6 months and will be divided into two phases of three months each. The two groups will crossover after 3 months. The primary outcome is the 10-day antibiotic prescription rate of physicians. The secondary outcome is the rational use of antibiotic prescriptions. The acceptability and feasibility of this feedback intervention study will be evaluated using both qualitative and quantitative assessment methods.DiscussionThis study will overcome limitations of our previous study, which only focused on reducing antibiotic prescription rates. AI techniques and an educational intervention will be used in this study to effectively reduce antibiotic prescription rates and antibiotic irregularities. This study will also provide new ideas and approaches for further research in this area.Trial registrationISRCTN, ID: ISRCTN13817256. Registered on 11 January 2020.

The overuse and abuse of antibiotics is a major risk factor for antibiotic resistance in primary care settings of China. In this study, the effectiveness of an automatically-presented, privacy-protecting, computer information technology (IT)-based antibiotic feedback intervention will be evaluated to determine whether it can reduce antibiotic prescribing rates and unreasonable prescribing behaviours. We will pilot and develop a cluster-randomised, open controlled, crossover, superiority trial. A total of 320 outpatient physicians in 6 counties of Guizhou province who met the standard will be randomly divided into intervention group and control group with a primary care hospital being the unit of cluster allocation. In the intervention group, the three components of the feedback intervention included: 1. Artificial intelligence (AI)-based real-time warnings of improper antibiotic use; 2. Pop-up windows of antibiotic prescription rate ranking; 3. Distribution of educational manuals. In the control group, no form of intervention will be provided. The trial will last for 6 months and will be divided into two phases of three months each. The two groups will crossover after 3 months. The primary outcome is the 10-day antibiotic prescription rate of physicians. The secondary outcome is the rational use of antibiotic prescriptions. The acceptability and feasibility of this feedback intervention study will be evaluated using both qualitative and quantitative assessment methods. This study will overcome limitations of our previous study, which only focused on reducing antibiotic prescription rates. AI techniques and an educational intervention will be used in this study to effectively reduce antibiotic prescription rates and antibiotic irregularities. This study will also provide new ideas and approaches for further research in this area. ISRCTN, ID: ISRCTN13817256. Registered on 11 January 2020.

Despite the need for rational allocation of resources and cooperation between different treatment settings, clinical differences in patients with major depressive disorder (MDD) between primary and psychiatric care remain obscure. We investigated these differences in representative patient populations from primary care versus secondary level psychiatric care in the city of Vantaa, Finland. We compared MDD patients from primary care in the Vantaa Primary Care Depression Study (PC-VDS) (n=79) with psychiatric out-patients (n=223) and in-patients (n=46) in the Vantaa Depression Study (VDS). DSM-IV diagnoses were assigned by the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I in PC-VDS) or Schedules for Clinical Assessment in Neuropsychiatry (SCAN in VDS), and SCID-II interviews. Comparable information was collected on depression severity, Axis I and II co-morbidity, suicidal behaviour, preceding clinical course, and attitudes towards and pathways to treatment. Prevalence of psychotic subtype and severity of depression were highest among in-patients, but otherwise few clinical differences between psychiatric and primary care patients were detected. Suicide attempts, alcohol dependence, and cluster A personality disorder were associated with treatment in psychiatric care, whereas cluster B personality disorder was associated with primary care treatment. Patients' choice of the initial point of contact for current depressive symptoms seemed to be independent of prior clinical history or attitude towards treatment. Severe, suicidal and psychotic depression cluster in psychiatric in-patient settings, as expected. However, MDD patients in primary care or psychiatric out-patient settings may not differ markedly in their clinical characteristics. This apparent blurring of boundaries between treatment settings calls for enhanced cooperation between settings, and clearer and more structured division of labour.

C-reactive protein (CRP) point-of-care testing (POCT) can be a valuable tool for decision making in primary care. Very few studies have illustrated the utilization of CRP POCT. To conduct a systematic review on the use of CRP POCT in primary care settings and to examine its feasibility and acceptability in an outpatient primary care setting. The search was conducted via PubMed. Final articles in the systematic review met inclusion and exclusion criteria. For the feasibility and acceptability analysis, a convenience sample of 20 adult subjects was enrolled and CRP POCT was conducted. Antibiotic prescription was the most predominant outcome assessed, and antibiotic prescription reduction was the most common finding of CRP POCT effectiveness testing. CRP POCT can be used to detect inflammation and can reduce antibiotic prescription in primary care. It is a satisfactory procedure that should be available in the primary care setting.