Adult Visits Research Articles

Functional decline in persons with haemophilia and factors associated with deterioration

The World Haemophilia Federation advises regular musculoskeletal assessment covering all International Classification of Functioning and Health (ICF) domains, including limitations in activities and participation in persons with haemophilia (PWH). This enables clinicians to detect changes early and enable adjustments in personalized healthcare when needed. However, data on the course of physical functioning and occurrence of decline is lacking. The aim of this study is to describe changes in perceived limitations in activities of PWH and to identify factors associated with a change. Data were collected from medical health records of regular check-up visits of adults with moderate and severe haemophilia in two time periods. Perceived limitations in activities was measured with the Haemophilia Activities List (HAL). Association between variables (e.g., age, body mass index, bleeding rate and synovitis) and change in perceived limitations was assessed using a generalized linear model. A total of 104 PWH were included. At T0, the median HAL sum score was 79.5 (IQR 62.1-93.6) and at T1 the median HAL sum score was 74.2 (IQR 57.5-88.3). A functional decline was found in 35.6% of PWH, 55.8% remained stable and 8.7% improved. Among other variables, a BMI>30kg/m2 appeared to be an important factor that negatively influenced the change in perceived functioning in adult PWH. With the included factors we could only explain a small part of this decline (R2 adj : .12). The majority of PWH remained stable in their perceived functional ability over mid-long term (median 3.5 years). However, about a third showed a clinical relevant decline in their functional ability.

Nurses' experiences of managing COVID-19 contact tracing clinics in a tertiary care hospital.

The COVID-19 pandemic spread rapidly globally, making the WHO to declare it a public health emergency of international concern. The ability of health institutions to screen and test for COVID-19 has been critical in detecting, preventing, and managing the spread of the disease. This report documents lessons from the ambulatory care nursing for COVID-19 contact tracing at a tertiary care hospital. In March 2020, a multidisciplinary team consisting of staff of the Primary Healthcare Services, Ambulatory Care Center, Infection Prevention and Control Department, and Nursing Services at the Ministry of National Guard Health Affairs in Riyadh, Saudi Arabia, worked collaboratively to establish 2 dedicated COVID-19 contact tracing clinics away from hospital premises, one clinic established for the public and another for hospital staff. Surveillance system was established to detect and contain as many cases as possible. This report highlights the process of establishing and maintaining the structure and managing workflow of the contact tracing clinics. We calculated the number of nasopharyngeal swabs and the daily average number of patient visits for both clinics between March 2020 and March 2021. Over the one-year period, the clinics served 79 146 visitors with an average of 52 visits for staff, 159 visits for adults, and 16 visits for children per day. The 2 clinics conducted 73 924 polymerase chain reaction tests. There was zero transmission of COVID-19 infection to staff working at both clinics. Despite the challenge of setting up contact tracing clinics, the decision to use separate geographic locations contributed to reducing the risk of infection exposure among staff of the clinics. Effective implementation of contact tracing interventions relies on interdepartmental cooperation and effective communication to contain the risk of viral spread.

Unexpected association between ambient ozone and adult insomnia outpatient visits: A large-scale hospital-based study

Growing evidence indicates that short-term ozone (O3) exposure has substantial health consequences, but the relationship between short-term ambient O3 and insomnia, a common sleep disorder, is not clear. This study aimed to investigate the short-term effects of ambient O3 exposure on outpatient visits for adult insomnia and to explore the potential modifiers. A large-scale multihospital-based study was carried out in Chongqing, the largest city in Southwest China. Daily data on outpatient visits for adult insomnia, average concentrations of ambient air pollutants and meteorological factors were collected. We conducted quasi-Poisson regression with generalized additive model to assess the association between ambient O3 and outpatient visits for adult insomnia in varied windows of exposure. Subgroup analyses were applied to identify its modifiers. Totally, 140,159 adult insomnia outpatient visits were identified. The daily maximum 8-h average concentration of O3 was 69 μg/m3 during the study period, which greatly below the updated Chinese and WHO recommended limits (daily maximum 8-h average, O3: 100 μg/m3). Short-term O3 exposure was significantly negatively associated with outpatient visits for adult insomnia in different lag periods and the greatest decrease of outpatient visits for adult insomnia was found at lag 02 [0.93% (95% CI: 0.48%, 1.38%)]. Additionally, stronger links between O3 and adult insomnia outpatient visits were presented in cool seasons, and we did not observe any significant modified effects of gender and age. Moreover, the negative O3-insomnia association remained robust after controlling for other common air pollutants and comorbidities. In summary, short-term exposure to lower level of ambient O3, was associated with reduced daily outpatient visits for adult insomnia and such association showed to be more obvious in cool seasons.

Patient satisfaction with telemedicine in the Philippines during the COVID-19 pandemic: a mixed methods study

BackgroundThe capacity to deliver essential health services has been negatively impacted by the COVID-19 pandemic, particularly due to lockdown restrictions. Telemedicine provides a safe, efficient, and effective alternative that addresses the needs of patients and the health system. However, there remain implementation challenges and barriers to patient adoption in resource-limited settings as in the Philippines. This mixed methods study aimed to describe patient perspectives and experiences with telemedicine services, and explore the factors that influence telemedicine use and satisfaction.MethodsAn online survey consisting of items adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician & Group Adult Visit Survey 4.0 (beta) and the Telehealth Usability Questionnaire (TUQ) was completed by 200 participants aged 18 to 65 years residing in the Philippines. A subsample of 16 participants was interviewed to provide further insights on their experiences. We used descriptive statistics to analyze survey data and thematically analyzed data from interviews guided by the principles of grounded theory.ResultsParticipants were generally satisfied with telemedicine, and found it to be an efficient and convenient means of receiving healthcare. About 3 in 5 perceived telemedicine as affordable, with some finding telemedicine costs to be high and comparable to in-person consultations. Our results suggest that participants preferred telemedicine services, especially in cases where they feel that their condition is not urgent and does not need extensive physical examination. Safety against COVID-19, privacy, accessibility, and availability of multiple communication platforms contributed to patient satisfaction with telemedicine. Negative perceptions of patients on quality of care and service related to their telemedicine provider, inherent limitations of telemedicine in the diagnosis and management of patients, perceived high costs especially for mental health conditions, and poor connectivity and other technological issues were barriers to telemedicine use and satisfaction.ConclusionTelemedicine is viewed as a safe, efficient, and affordable alternative to receiving care. Expectations of patients on costs and outcomes need to be managed by providers to increase satisfaction. Continued adoption of telemedicine will require improvements in technology infrastructure and technical support for patients, training and performance evaluation of providers to ensure quality of care and service, better patient communication to meet patient needs, and integration of telemedicine services in remote areas that have limited access to medical services. Telemedicine, to realize its full potential, should be centered in health equity – addressing patient barriers and needs, reducing health disparities across population groups and settings, and providing quality services to all.

Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care

BackgroundGuidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations. ObjectiveWe sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians. MethodsThis was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering. ResultsAmong 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99–12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08–3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51–0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62–0.91) or no insurance (OR 0.54; 95% CI 0.35–0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period. ConclusionsAn ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.

Recent trends in the prescription of opioids in the emergency department in patients with urolithiasis.

Pain management is central in the treatment of urolithiasis. We aimed to estimate the impact of the 2017 Department of Health and Human Services declaration of an opioid crisis on prescribing patterns of opioids and NSAIDs in emergency department visits for urolithiasis. The National Health Ambulatory Medical Care Survey (NHAMCS) was queried for emergency department visits of adults with a diagnosis of urolithiasis. The association between urolithiasis and narcotic and NSAIDs prescription patterns was evaluated and compared at pre-declaration (2014-2016) to post-declaration (2017-2018) periods. Opioids were prescribed in about 211 million (41.1%) out of 513 million emergency department visits, over a 5-year period. Diagnosis of urolithiasis accounted for 1.9% of the visits (6.0 million). The use of opioids was higher in urolithiasis (82.7%) compared to non-urolithiasis diagnosis (40.3%), as well as the use of multiple opioids per visit (p < 0.01 for all). There was an overall decrease in opioid prescriptions in the post-declaration period, -4.3% for urolithiasis (p = 0.254) and -5.6% for non-urolithiasis visits (p < 0.05). A decrease in the use of hydromorphone (-47.5%. p < 0.001), an increase in the use of morphine (+ 59.7% p = 0.006), and an increase of 'other' opioids (+ 98.8%, p < 0.041), were observed. Opioids combined with NSAIDs comprised 72.6% of the opioid prescriptions and 62.3% of all analgesic prescriptions in visits with urolithiasis diagnosis. The use of opioids when managing urolithiasis decreased 4.3% after the crisis declaration; however, statistically are not different from pre-declaration numbers. Most often, opioids were prescribed with NSAIDs in urolithiasis patients.

When Musculoskeletal Clinicians Respond to Empathetic Opportunities, do Patients Perceive Greater Empathy?

Patient use of verbal and nonverbal communication to signal what is most important to them can be considered empathetic opportunities. Orthopaedic surgeons may have mixed feelings toward empathetic opportunities, on one hand wanting the patient to know that they care, and on the other hand fearing offense, prolonged visit duration, or discussions for which they feel ill prepared. Evidence that action about empathetic opportunities does not harm the patient's experience or appreciably prolong the visit could increase the use of these communication tactics with potential for improved experience and outcomes of care. Using transcripts from musculoskeletal specialty care visits in prior studies, we asked: (1) Are there factors, including clinician attentiveness to empathetic opportunities, associated with patient perception of clinician empathy? (2) Are there factors associated with the number of patient-initiated empathetic opportunities? (3) Are there factors associated with clinician acknowledgment of empathetic opportunities? (4) Are there factors associated with the frequency with which clinicians elicited empathetic opportunities? This study was a retrospective, secondary analysis of transcripts from prior studies of audio and video recordings of patient visits with musculoskeletal specialists. Three trained observers identified empathetic opportunities in 80% (209 of 261) of transcripts of adult patient musculoskeletal specialty care visits, with any uncertainties or disagreements resolved by discussion and a final decision by the senior author. Patient statements considered consistent with empathetic opportunities included relation of emotion, expression of worries or concerns, description of loss of valued activities or loss of important roles or identities, relation of a troubling psychologic or social event, and elaboration on daily life. Clinician-initiated empathetic opportunities were considered clinician inquiries about these factors. Clinician acknowledgment of empathetic opportunities included encouragement, affirmation or reassurance, or supportive statements. Participants completed post-visit surveys of perceived clinician empathy, symptoms of depression, and health anxiety. Factors associated with perceived clinician empathy, number of empathetic opportunities, clinician responses to these opportunities, and the frequency with which clinicians elicited empathetic opportunities were sought in bivariate and multivariable analyses. After controlling for potentially confounding variables such as working status and pain self-efficacy scores in the multivariable analysis, no factors were associated with patient perception of clinician empathy, including attentiveness to empathetic opportunities. Patient-initiated empathetic opportunities were modestly associated with longer visit duration (correlation coefficient 0.037 [95% confidence interval 0.023 to 0.050]; p < 0.001). Clinician acknowledgment of empathetic opportunities was modestly associated with longer visit duration (correlation coefficient 0.06 [95% CI 0.03 to 0.09]; p < 0.001). Clinician-initiated empathetic opportunities were modestly associated with younger patient age (correlation coefficient -0.025 [95% CI -0.037 to -0.014]; p < 0.001) and strongly associated with one specific interviewing clinician as well as other clinicians (correlation coefficient -1.3 [95% CI -2.2 to -0.42]; p = 0.004 and -0.53 [95% CI -0.95 to -0.12]; p = 0.01). Musculoskeletal specialists can respond to empathic opportunities without harming efficiency, throughput, or patient experience. Given the evidence that patients prioritize feeling heard and understood, and evidence that a trusting patient-clinician relationship is protective and healthful, the results of this study can motivate specialists to train and practice effective communication tactics.

Changes in Prevalence Over Time and Determinants of Dental Care Visits Amongst Tennessee Seniors

Rates of dental visits of older adults in the United States, particularly in Tennessee, are rapidly increasing, coupled with the growing complexity of older adults' dental treatment. Notably, increased dental visits help detect and treat dental disease and offer opportunities for preventive care. This longitudinal study aimed to examine the prevalence and determinants of dental care visits amongst Tennessee seniors. This observational study combined multiple cross-sectional studies. Five even years of Behavioral Risk Factor Surveillance system data were used, including 2010, 2012, 2014, 2016, and 2018. Our data were limited to Tennessee seniors (60 years or older). Weighting was conducted to account for the complex sampling design. Logistic regression analysis was performed to determine the factors associated with dental clinic visits. A P value < .05 was considered statistically significant. The current study comprised 5362 Tennessee seniors. Older individuals visiting dental clinics within 1 year gradually decreased from 76.5% in 2010 to 71.2% in 2018. The majority of participants were female (51.7%), White (81.3%), and located in Middle Tennessee (43.5%). Logistic regression showed that those more likely to visit dentists or dental clinics included females (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.8), never-smokers and former smokers (OR, 2.2; 95% CI, 1.5-3.4), individuals with some college education (OR, 1.6; 95% CI, 1.1-2.4), college graduates (OR, 2.7; 95% CI, 1.8-4.1), and those with high incomes (eg, >$50,000; OR, 5.7; 95% CI, 3.7-8.7). Conversely, Black participants (OR, 0.6; 95% CI, 0.4-0.8), participants with fair/poor health (OR, 0.7; 95% CI, 0.5-0.8), and those who have never married (OR, 0.5; 95% CI, 0.3-0.8) were less likely to report dental visits. Rates of Tennessee seniors visiting dental clinics within 1 year have gradually decreased from 76.5% in 2010 to 71.2% in 2018. Several factors were associated with seniors seeking dental treatment. Effective interventions to improve dental visits should take the identified factors into account.

N10 Facilitators and inhibitors to first adult care visits in the transition from paediatric to adult orientated Inflammatory Bowel Disease healthcare

Abstract Background Inflammatory bowel disease (IBD) can be a very debilitating disease and it is found to be more extensive in children with rapid early progression. The successful transition of patients from paediatric to adult-oriented services is essential to prevent disruption in care and negative effects on long-term health outcomes. In particular, the attendance at the first adult care visits are a pivotal phase of a successful transition process to ensure continuity and retention in care. The aim of this study is to explore the inhibitors and facilitators to first adult care visits in the transition process from paediatric to adult oriented IBD healthcare. Methods An exploratory, descriptive, qualitative approach was employed, underpinned by a transition theory (Meleis, 2010). A purposive sample of seven participants (over 16 years of age) diagnosed with IBD, who transitioned in the last four years, were recruited, through two clinical sites in Ireland, and an IBD support organisation. Online semi-structured interviews were conducted via Microsoft Teams and data were analysed using content analysis. Results Three main themes were identified including the ‘perception of transition’, ‘knowledge and preparation’ and ‘being an adolescent with IBD’. The themes illuminate various inhibitors and facilitators to the first adult care visits. The theme perception of transition revealed that joint care visits and adult healthcare teams that actively engage with adolescents during the first adult care visits were facilitators, whereas difficulties contacting the adult services, lack of effective follow up and the change in language were inhibitors. More than one joint visit with the adult and paediatric healthcare teams and active promotion of independence facilitated knowledge and preparation for the first adult care visits. In contrast, a limited focus on disease management education and significant parental involvement inhibited the development of knowledge and preparation for the first adult care visits. Addressing adolescent specific topics, such as sexual health, and the availability of IBD supports, such as an IBD psychologist, social media platforms and meeting peers with IBD, supported being an adolescent with IBD and facilitated the first adult care visits. Conclusion Multiple, organised joint care visits with an active focus on promoting independence and providing education on disease management and adolescent specific topics, using age appropriate language, facilitates first adult care visits. Identifying the inhibitors and facilitators provide insights for healthcare professionals in supporting a successful transition process and highlights the need for transition policies and structured transition programmes.

The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial: rationale and design of an emergency department-based randomized clinical trial of linkage-to-care strategies for hepatitis C

BackgroundHepatitis C (HCV) poses a major public health problem in the USA. While early identification is a critical priority, subsequent linkage to a treatment specialist is a crucial step that bridges diagnosed patients to treatment, cure, and prevention of ongoing transmission. Emergency departments (EDs) serve as an important clinical setting for HCV screening, although optimal methods of linkage-to-care for HCV-diagnosed individuals remain unknown. In this article, we describe the rationale and design of The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial.MethodsThe DETECT Hep C Linkage-to-Care Trial will be a single-center prospective comparative effectiveness randomized two-arm parallel-group superiority trial to test the effectiveness of linkage navigation and clinician referral among ED patients identified with untreated HCV with a primary hypothesis that linkage navigation plus clinician referral is superior to clinician referral alone when using treatment initiation as the primary outcome. Participants will be enrolled in the ED at Denver Health Medical Center (Denver, CO), an urban, safety-net hospital with approximately 75,000 annual adult ED visits. This trial was designed to enroll a maximum of 280 HCV RNA-positive participants with one planned interim analysis based on methods by O’Brien and Fleming. This trial will further inform the evaluation of cost effectiveness, disparities, and social determinants of health in linkage-to-care, treatment, and disease progression.DiscussionWhen complete, the DETECT Hep C Linkage-to-Care Trial will significantly inform how best to perform linkage-to-care among ED patients identified with HCV.Trial registrationClinicalTrials.govID: NCT04026867Original date: July 1, 2019URL: https://clinicaltrials.gov/ct2/show/NCT04026867

Social Determinants of Health and Adverse Health Outcomes in an Urban Community Hospital in Northwest Indiana

Background: Social determinants of health (SDOH) are underlying contributing factors ofhealth inequities. Facility-based SDOH screenings inform targeted care, community resource referrals, and actions. St. Mary Medical Center (SMMC), an urban hospital in Northwest Indiana, was first acute care hospital in the state to pilot comprehensive SDOH screenings and referrals using the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences(PRAPARE), a nationally recognized and validated tool. This study is part of a three-phased Community Based Participatory Research (CBPR) partnership between SMMC and IUSM-NWto examine and address SDOH from January 2021-January 2025. This study’s research questions are: What is the distribution of adverse health outcomes by demographics and by SDOH in SMMC’s inpatients?&#x0D; Methods: This descriptive study analyzed a limited dataset generated from EPIC™ by SMMC. It included demographics, behavioral, health outcomes, and SDOH measures for adult inpatient visits from January 2021 to June 2022. Data analysis was conducted in SPSS 28.0 usingdescriptive statistics and tests of association (p&lt;0.05) including One-way ANOVA, Kruskal Wallis H, Chi-square, and Fisher’s Exact. This study was exempted by Indiana UniversityHuman Research Protection Program (IRB #14040).&#x0D; Results: The sample comprised 4370 patients, majority non-Hispanic (90.4%), White (75.7%), older adults (median age 65, IQR = 24), and publicly insured (76.3%). 30-day readmissions accounted for 9.1%. The top three discharge diagnoses were diseases of the circulatory system (20%), digestive system (12.4%), and injury (7.5%). Discharge diagnoses differed significantly (p&lt;.001) by family income, insurance type, stress presence, race, ethnicity, and sex. 30-day readmission was significantly associated with housing risk (p=.036) and insurance type (p&lt;.001).&#x0D; Conclusions: This study underscores the role of SDOH in influencing health outcomes and the importance of continuous SDOH screenings. This study will inform subsequent advanced analysis, the program evaluation, and the translation-to-action phase of the CBPR project.

Relationships Between Health Behaviors, Social Determinants of Health, and Patient Demographics in an Urban Northwest Indiana Hospital

Background: Social determinants of health (SDOH) contribute to over 50% of health outcomes and inequities. Healthcare institutions are increasingly implementing SDOH screenings and referrals. St. Mary Medical Center (SMMC) in Northwest Indiana was the first acute care hospital to implement a comprehensive SDOH pilot screening and referral program in Indiana using the validated Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). This study is part of a three-phased Community-Based Participatory Research (CBPR) partnership between IUSM-NW and SMMC to examine and address SDOH within SMMC’s service area from January 2022-January 2025. This study’s research question is: What are the relationships between SDOH, behavioral, and demographic factors in SMMC’s inpatients?Methods: This descriptive study analyzed a limited dataset generated by SMMC from EPIC™ with SDOH, demographic, behavioral (tobacco use, alcohol use, physical activity), and health outcomes data for adult inpatient visits from January 2021 to June 2022. Data analysis was conducted in SPSS 28.0 using descriptive statistics (i.e., frequencies and central tendency) and tests of association including Chi-square, Fisher’s Exact, Wilcoxon-Mann Whitney, and Kruskal Wallis H (p&lt;0.05). This study was exempted by Indiana University Human Research Protection Program (IRB # 14040).Results: This study included 4370 inpatients, who were predominantly White (75.7%), older adults (65 ± 24), and publicly insured (76.3%). There were significant relationships between SDOH and tobacco use, alcohol use, and physical activity. Tobacco use was significantly associated with the majority of SDOH including insurance type (p&lt;.001), housing risk (p&lt;.001), financial resource risk (p&lt;.001), unmet transportation needs (p&lt;.001), and overall social risk (p=.012).Conclusions: Understanding how SDOH influence health behaviors will inform efforts to develop, implement, and evaluate multi-level interventions. The next phases of this CBPR will use advanced statistical techniques to further explore these relationships, evaluate SMMC’s pilot program, and co-develop SDOH interventions.

Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool.

Patients and families are key partners in diagnosis, but methods to routinely engage them in diagnostic safety are lacking. Policy mandating patient access to electronic health information presents new opportunities. We tested a new online tool ("OurDX") that was codesigned with patients and families, to determine the types and frequencies of potential safety issues identified by patients/families with chronic health conditions and whether their contributions were integrated into the visit note. Patients/families at 2 US healthcare sites were invited to contribute, through an online previsit survey: (1) visit priorities, (2) recent medical history/symptoms, and (3) potential diagnostic concerns. Two physicians reviewed patient-reported diagnostic concerns to verify and categorize diagnostic safety opportunities (DSOs). We conducted a chart review to determine whether patient contributions were integrated into the note. We used descriptive statistics to report implementation outcomes, verification of DSOs, and chart review findings. Participants completed OurDX reports in 7075 of 18129 (39%) eligible pediatric subspecialty visits (site 1), and 460 of 706 (65%) eligible adult primary care visits (site 2). Among patients reporting diagnostic concerns, 63% were verified as probable DSOs. In total, probable DSOs were identified by 7.5% of pediatric and adult patients/families with underlying health conditions, respectively. The most common types of DSOs were patients/families not feeling heard; problems/delays with tests or referrals; and problems/delays with explanation or next steps. In chart review, most clinician notes included all or some patient/family priorities and patient-reported histories. OurDX can help engage patients and families living with chronic health conditions in diagnosis. Participating patients/families identified DSOs and most of their OurDX contributions were included in the visit note.

Trends in Provision of Medications and Lifestyle Counseling in Ambulatory Settings by Gender and Race for Patients With Atherosclerotic Cardiovascular Disease, 2006-2016

Atherosclerotic cardiovascular disease (ASCVD) continues to be highly prevalent in the US. The 2013 American College of Cardiology and American Heart Association (ACC/AHA) treatment guidelines reevaluated evidence-based practices for reduction of ASCVD in men and women from high-quality randomized trials and meta-analyses recommending the use of statin therapy, aspirin prescription, and lifestyle counseling for adults with ASCVD. Population trends in secondary prevention strategies for patients with ASCVD among primary care settings is currently lacking, limiting ability to evaluate impact of guideline implementation. To examine temporal and sociodemographic trends in secondary prevention strategies in patients with ASCVD between 2006 and 2016 in a nationally representative, ambulatory care database. This cross-sectional study analyzed data from the National Ambulatory Medical Care Survey (NAMCS), which is an annual survey conducted to represent the national US population and contains information on ambulatory office-based patient visits, including medical conditions, services provided, and demographic characteristics. Participants were adults aged 21 years and older with prevalent ASCVD identified via International Classification of Disease codes between 2006 and 2016. Data were extracted and analyzed in March 2021. Data were separated by calendar year pre-2013 (2006 to 2013) and post-2013 (2014 to 2016). Outcomes included statin therapy, aspirin prescription, and lifestyle counseling (eg, nutrition, exercise, weight reduction) service provided at clinic visits. There were 11 033 visits for adults with ASCVD, representing a weighted total of 275.3 million visits nationwide; 40.7% (112.1 million [weighted]) were women, 9.2% (25.4 million [weighted]) were Hispanic, 9.9% (19.0 million [weighted]) were non-Hispanic Black, 90.1% (172.7 million [weighted]) were non-Hispanic White, and 40.6% (112.1 million [weighted]) were from cardiology clinics. Of 11 033 patient visits, 5507 patients (49.9%) were prescribed statin therapy, 5165 patients (46.8%) were using aspirin, 2233 patients (20.2%) received lifestyle counseling. Statin therapy increased from 9.3 million individuals (45.3%) in 2006 to 14.9 million individuals (46.5%) in 2016, and aspirin prescriptions increased from 8.5 million individuals (41.3%) in 2006 to 15.2 individuals (47.5%) in 2016. Women were less likely than men to receive medications for secondary prevention: among women, 48.8 million (43.3%) received statins (vs 85.9 million men [52.7%]), 44.7 million (39.8%) received aspirin (vs 79.1 million men [48.5%]), and 25.7 million (22.9%) received lifestyle counseling services (vs 37.5 million men [23.0%]). These findings suggest only modest increases in statin and aspirin prescription since 2006; however, lifestyle counseling use decreased in recent years. Women and Black patients continued to be less likely to receive secondary prevention ASCVD treatment. Adherence to guideline-directed secondary prevention recommendations remained low (less than 50%) in patients with ASCVD, especially with regards to lifestyle counseling, suggesting the need for more implementation research.

Implementing a Fall Prevention Initiative in Nurse-Facilitated Annual Wellness Visits: A Quality Improvement Project.

Falls are the leading cause of injury-related death and disability in community-dwelling older adults. Evidence-based fall prevention activities in primary care, including nurse-facilitated wellness visits, have been limited. Barriers including patient engagement and adherence exist. A quality improvement project integrating components of the Centers for Disease Control and Prevention's Stopping Elder Accidents, Deaths & Injury (STEADI) was introduced by registered nurses during older adult annual wellness visits. Nurses assessed risk and implemented patient-centered fall prevention plans including follow-up. A total of 522 patients were screened, with 21% (n = 111) having increased fall risk. Of these, 78% (n = 87) engaged in home safety, gait, strength, and balance assessments and the majority (n = 83; 95%) participated in fall prevention plans of care. At 2-week follow-up, patients' self-reported adherence was 74% for gait/strength/balance and 67% for home safety. An expanded primary care team model shows promise for promoting fall prevention behaviors.

The longhorn beetles (Coleoptera: Cerambycidae) of Kentucky with notes on larval hosts, adult nectar use, and semiochemical attraction

The longhorn beetle fauna of Kentucky has long been overlooked in the literature with revisions and historic publications reporting few records from the state. Here, we document the occurrence of 222 species of Cerambycidae in Kentucky, with 140 new state records. For each species, we summarize its distribution (overall and in the state), the counties, years, and months in which it has been collected, collecting methods, what collections house the specimens, larval host plants, adult flower visitation, chemical lure attraction, recent taxonomic changes, and other pertinent information about the species. Using this dataset, the bias-corrected Chao1 species richness estimator predicted that 241 species should be found in Kentucky, indicating that our sampling is nearly comprehensive. Additionally, we provide a list of 42 species that have been found in at least one neighboring state and the distance from the closest record of the species to Kentucky; among this candidate list are 11 species known from within 50 km of the state. This checklist remedies the historical oversight of Kentucky cerambycid diversity in the literature, and we hope it will serve as a resource for future collectors, particularly the information on chemical lure attraction, which has not been summarized to this extent for any other state to date.

Clinical narrative-aware deep neural network for emergency department critical outcome prediction

Since early identification of potential critical patients in the Emergency Department (ED) can lower mortality and morbidity, this study seeks to develop a machine learning model capable of predicting possible critical outcomes based on the history and vital signs routinely collected at triage. We compare emergency physicians and the predictive performance of the machine learning model. Predictors including patients’ chief complaints, present illness, past medical history, vital signs, and demographic data of adult patients (aged ≥ 18 years) visiting the ED at Shuang-Ho Hospital in New Taipei City, Taiwan, are extracted from the hospital’s electronic health records. Critical outcomes are defined as in-hospital cardiac arrest (IHCA) or intensive care unit (ICU) admission. A clinical narrative-aware deep neural network was developed to handle the text-intensive data and standardized numerical data, which is compared against other machine learning models. After this, emergency physicians were asked to predict possible clinical outcomes of thirty visits that were extracted randomly from our dataset, and their results were further compared to our machine learning model. A total of 4,308 (2.5 %) out of the 171,275 adult visits to the ED included in this study resulted in critical outcomes. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) of our proposed prediction model is 0.874 and 0.207, respectively, which not only outperforms the other machine learning models, but even has better sensitivity (0.95 vs 0.41) and accuracy (0.90 vs 0.67) as compared to the emergency physicians. This model is sensitive and accurate in predicting critical outcomes and highlights the potential to use predictive analytics to support post-triage decision-making.

Life Satisfaction and Dental Visits in Adults Aged ≥50 Years and Living with Diabetes Mellitus: A Comparison between Urban and Rural Mexican.

To examine the association between low life satisfaction with past-year dental visits in a rural-urban national sample of 50-year-old Mexican adults with diabetes mellitus (DM). Data are drawn from the Mexican Health and Aging Study (MHAS), a cross-sectional study conducted in 2018 involving 3,592 older adults aged 50 years and older and living in urban and rural areas in Mexico. Life satisfaction was measured using the Satisfaction with Life Scale (SWLS) and past-year dental visits dichotomized as none and ≥1 dental visits. The Poisson regression analyses were used to assess the association, adjusting for confounders. 62.9% were women, mean age was 65.5 (±9.6), and 16.5% lived in a rural area, while the female subjects continue to present a higher probability of visiting a dentist (PR = 1.28 (95% CI 1.08-1.51)). In terms of age, the ≥70-year group presented 28% lower possibility of visiting a dentist (PR = 0.72 (95% CI 0.60-0.86)). The interaction showed that adults ≥50 years who reside in a rural area and have low life satisfaction were 40% less likely to have visited a dentist in the last year (PR = 0.60 (95% CI 0.37-0.98)) than adults ≥50 years who reside in an urban area and have high life satisfaction. The present study highlights the association between low life satisfaction and past-year dental visits in rural populations. Therefore, rurality should be considered a possible confounder in analysis of life satisfaction in the older adult population.

Association between Frequency or Confidence of ICT Devices Utilization and Self-efficacy of Neighborhood Watch or Frequency of Home Visits for Older Adults among Local Volunteers

Association between Frequency or Confidence of ICT Devices Utilization and Self-efficacy of Neighborhood Watch or Frequency of Home Visits for Older Adults among Local Volunteers

Modified Shock Index as a Predictor of Admission and In-hospital Mortality in Emergency Departments; an Analysis of a US National Database.

The modified shock index (MSI) is the ratio of heart rate to mean arterial pressure. It is used as a predictive and prognostic marker in a variety of disease states.This study aimed to derive the optimal MSI cut-off that is associated with increased likelihood (likelihood ratio, LR) of admission and in-hospital mortality in patients presenting to emergency department (ED). We retrospectively reviewed data from the National Hospital Ambulatory Medical Care Survey between 2005 and 2010. Adults>18 years of age were included regardless of chief complaint. Basic patient demographics, initial vital signs, and outcomes were recorded for each patient. Then the optimal MSI cut-off for prediction of admission and in-hospital mortality in ED was calculated. LR ≥ 5 was considered clinically significant. 567,994,402 distinct weighted adult ED patient visits were included in the analysis. 15.7% and 2.4% resulted in admissions and in-hospital mortality, respectively. MSI > 1.7 was associated with a moderate increase in the likelihood of both admission (Positive LR (+LR) = 6.29) and in-hospital mortality (+LR = 5.12). +LR for hospital admission at MSI >1.7 was higher for men (7.13; 95% CI 7.11-7.15) compared to women (5.49; 95% CI 5.47-5.50) and for non-white (7.92; 95% CI 7.88-7.95) compared to white patients (5.85; 95% CI 5.84-5.86). For MSI <0.7, the +LRs were not clinically significant for admission (+LR = 1.07) or in-hospital mortality (LR = 0.75). In this largest retrospective study, to date, on MSI in the undifferentiated ED population, we demonstrated that an MSI >1.7 on presentation is predictive of admission and in-hospital mortality. The use of MSI could help guide accurate acuity designation, resource allocation, and disposition.