Ambulatory Clinic Visit Research Articles

The Impact of the COVID-19 Pandemic on Diabetes Self-Management in Saudi Arabia.

The COVID-19 pandemic disrupted healthcare worldwide, potentially impacting disease management. The objective of this study was to assess the self-management behaviors of Saudi patients with diabetes during and after the COVID pandemic period using the Arabic version of the Diabetes Self-Management Questionnaire (DSMQ). A cross-sectional study was conducted in patients aged ≥18 years diagnosed with type 2 diabetes mellitus who had at least one ambulatory clinic visit in each of the specified time frames (Pre-COVID-19: 1 January 2019-21 March 2020; COVID-19 Time frame: 22 March 2020 to 30 April 2021) utilizing the DSMQ questionnaire, with an additional three questions specifically related to their diabetes care during the COVID pandemic. A total of 341 patients participated in the study. The study results revealed that the surveyed patients showed moderately high self-care activities post-COVID-19. Total DSMQ scores were significantly higher in patients aged >60 years versus younger groups (p < 0.05). Scores were significantly lower in patients diagnosed for 1-5 years versus longer durations (p < 0.05). Patients on insulin had higher glucose management sub-scores than oral medication users (p < 0.05). Overall, DSMQ scores were higher than the pre-pandemic Saudi population and Turkish post-pandemic findings. DSMQ results suggest that, while COVID-19 negatively impacted some self-management domains, the Saudi patients surveyed in this study upheld relatively good diabetes control during the pandemic. Further research is warranted on specific barriers to optimize diabetes care during public health crises.

Rural-urban disparities in health care delivery for children with medical complexity and moderating effects of payer, disability, and community poverty.

Children with medical complexity (CMC) may be at increased risk of rural-urban disparities in health care delivery given their multifaceted health care needs, but these disparities are poorly understood. This study evaluated rural-urban disparities in health care delivery to CMC and determined whether Medicaid coverage, co-occurring disability, and community poverty modified the effects of rurality on care delivery. This retrospective cohort study of 2012-2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire included CMC <18years. Health care delivery measures (ambulatory clinic visits, emergency department visits, acute care hospitalizations, total hospital days, and receipt of post-acute care) were compared for rural- versus urban-residing CMC in multivariable regression models, following established methods to evaluate effect modification. Of 112,475 CMC, 7307 (6.5%) were rural residing and 105,168 (93.5%) were urban residing. A total of 68.9% had Medicaid coverage, 33.9% had a disability, and 39.7% lived in communities with >20% child poverty. In adjusted analyses, rural-residing CMC received significantly fewer ambulatory visits (risk ratio [RR]=0.95, 95% confidence interval [CI]: 0.94-0.96), more emergency visits (RR=1.12, 95% CI: 1.08-1.16), and fewer hospitalization days (RR=0.90, 95% CI=0.85-0.96). The estimated modification effects of rural residence by Medicaid coverage, disability, and community poverty were each statistically significant. Differences in the odds of having a hospitalization and receiving post-acute care did not persist after incorporating sociodemographic and clinical characteristics and interaction effects. Rural- and urban-residing CMC differed in their receipt of health care, and Medicaid coverage, co-occurring disabilities, and community poverty modified several of these effects. These modifying effects should be considered in clinical and policy initiatives to ensure that such initiatives do not widen rural-urban disparities.

Efficacy, Efficiency, and Acceptability of Telemedicine for Inflammatory Bowel Disease Patients’ Follow-Up Care during the COVID-19 Pandemic

Background: During the COVID-19 pandemic, ambulatory clinic visits were replaced by the implementation of telehealth modalities in most inflammatory bowel disease (IBD) units. Aims: The aim of this study was to assess the efficacy, efficiency, patient satisfaction, and acceptability of using telephone consultation in an IBD unit. Methods: A prospective cohort study was performed in IBD patients who underwent telephone consultation during COVID-19 lockdown (between 16th March and 13th April 2020). To assess the efficacy of this telephone consultation (lockdown visit), nonscheduled visits, emergency consultation, hospital admission, and surgery from lockdown visit to the next scheduled consultation (post-lockdown) were checked. To evaluate efficiency, the time between lockdown visit and post-lockdown consultation was compared with previous consultation (pre-lockdown), and the total number of visits 12 months before and after lockdown visit was checked. A telephone survey was designed to rate perception for a telephone consultation. Results: Out of a total of 274 patients, 220 patients (52.2% male; mean age 49 ± 16 years; Crohn’s disease, n = 126; ulcerative colitis, n = 83; indeterminate colitis, n = 11) were included. Only one patient was consulted at the emergency department, 11 patients needed to rearrange the visit, and none patient underwent surgery before the scheduled post-lockdown visit. The interval to post-lockdown visit compared to pre-lockdown visit increased in 37.7% of patients. The satisfaction survey (n = 185) revealed that 94.6% perceived it was effective. However, 44.4% of patients rather prefer on-site consultation for follow-up. Conclusions: Telemedicine during the COVID-19 pandemic was shown to be effective and efficient to care for IBD patients. In addition, telephone consultation is well accepted by patients in non-extended follow-up periods.

Implementation of a herpes zoster immunization program in an outpatient hospital-based pharmacy

BackgroundAdministration of the recombinant zoster vaccine (RZV) in an ambulatory clinic visit is not covered by Medicare, and the pharmacy at Tufts Medical Center (TMC) had not previously offered immunizations, leaving clinicians to instruct their patients to receive RZV at outside pharmacies without close follow-up. ObjectiveImprove immunization access by standardizing administration of RZV for eligible patients at TMC. Practice descriptionTMC is an academic medical center that serves a vast patient population. The adult primary care clinic offers services for approximately 40,000 patients. Atrium 3 Pharmacy is a 340B hospital-based outpatient pharmacy located in TMC. Practice innovationPatient referrals for RZV administration were sent from the adult primary care clinic to a designated certified pharmacy technician (CPhT) working within the outpatient pharmacy. The CPhT contacted patients for cost disclosure and scheduling vaccination appointments. Evaluation methodsAfter the CPhT processed the referrals and scheduled the patient, they were then immunized at the herpes zoster clinic by a pharmacist and asked to complete a survey to assess their experience. ResultsOver a 3-month pilot period from January 1, 2022, to March 15, 2022, there were 151 patient referrals placed from the adult primary care clinic. A total of 50 patients received their first RZV dose and 10 patients received their second RZV dose for an overall total of 60 RZV doses. Survey results showed that 96% of patients answered that their overall satisfaction improved, with 57% of patients selecting that they strongly agree and 39% of patients selecting that they agree. ConclusionAn outpatient pharmacy-based herpes zoster vaccine immunization program was successfully established. Most patients found the expansion of services in the outpatient pharmacy satisfactory.

Abstract 10984: Alert-Based Computerized Decision Support for High-Risk Ambulatory Clinic Patients With Atrial Fibrillation Not Prescribed Anticoagulation: A Randomized, Controlled Trial (AF-Alert2)

Introduction: Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, antithrombotic therapy for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory clinic patients. Hypothesis: We hypothesized that alert-based computerized decision support (CDS) would increase anticoagulation prescription in ambulatory clinic patients with AF and high-risk for stroke. Methods: We enrolled 798 patients (CHA 2 DS 2- VASc score≥2) with AF who were not prescribed anticoagulant therapy and had an ambulatory clinic visit at Brigham and Women’s Hospital. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. Results: The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Patients in the alert group were more likely to be prescribed anticoagulation within 48 hours of the clinic visit (15.4% vs. 7.7%, p&lt;0.001) and at 90 days (17.2% vs. 9.9%, p&lt;0.01). Direct oral anticoagulants (DOACs) comprised the majority of increased prescriptions of anticoagulation at 48 hours and 90 days. No differences in stroke, TIA, or systemic embolic events (0% vs. 0.8%, p=0.09), symptomatic VTE (0.5% vs. 1%, p=0.43), CV mortality (0.5% vs. 0.7%, p=0.99), or a composite of major adverse cardiovascular events (2.8% vs. 2.5%, p=0.79) were observed at 90 days ( Figure ). Conclusions: An alert-based CDS strategy increased anticoagulation in ambulatory clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. ClinicalTrials.gov Identifier: NCT02958943

Disparities in adherence to diabetes screening guidelines among males and females in a universal care setting: A population-based study of 1,389,697 adults.

ObjectivesNational guidelines recommend that all adults over the age of 40 years undergo screening for diabetes at least once every 3-years. We examined the association between sex and adherence to diabetes screening after accounting for age, urban/rural residence and material deprivation. We also examined the subsequent incidence of prediabetes and diabetes in adherent and non-adherent individuals. ApproachOur study is based on a retrospective population-level inception cohort of adults aged 40 - 79 years without pre-existing diabetes or cardiovascular disease on April 1, 2013. Data on hospitalizations, emergency department visits, ambulatory clinic visits, physician billing claims, pharmaceutical claims, centralized laboratory data, vital statistics death registry, and census data at the neighbourhood level were linked at the patient level for years 2013 to 2020. Adherence during a 3-year screening period (2013 – 2016) and prediabetes and diabetes during a 4-year follow-up period were examined. Multivariate logistic regression was used to examine the adjusted association between sex and adherence. ResultsAmong 1,389,697 individuals (49.2% male, 50.8% female) adherence rates were 69.9% in males and 79.8% in females. Sex-differences in adherence were largest in younger individuals (58.0% and 72.6% and in males and females aged 40-44 years, respectively) and consistent across rural/urban residence and material deprivation categories. Females were more adherent (adjusted odds ratio 1.93; 95% confidence interval 1.90 to 1.97) than males. Among adherent males and females, 65.3% and 64.8% had at least one Haemoglobin A1C, respectively during the screening period. During the follow-up period, prediabetes and diabetes rates among males who were adherent were 25.9% and 5.2%, compared to 8.8% and 2.1% among non-adherent males; and 20.2% and 2.9% among adherent and 7.3% and 1.3% among non-adherent females. ConclusionsDespite lower rates of adherence to screening, males have higher rates of prediabetes and diabetes compared to females. Our study highlights the need to develop education campaigns and targeted interventions at the local and population level to raise awareness and improve diabetes screening rates in young people, especially males.

Point-of-care motion capture and biomechanical assessment improve clinical utility of dynamic balance testing for lower extremity osteoarthritis.

Musculoskeletal conditions impede patient biomechanical function. However, clinicians rely on subjective functional assessments with poor test characteristics for biomechanical outcomes because more advanced assessments are impractical in the ambulatory care setting. Using markerless motion capture (MMC) in clinic to record time-series joint position data, we implemented a spatiotemporal assessment of patient kinematics during lower extremity functional testing to evaluate whether kinematic models could identify disease states beyond conventional clinical scoring. 213 trials of the star excursion balance test (SEBT) were recorded by 36 subjects during routine ambulatory clinic visits using both MMC technology and conventional clinician scoring. Conventional clinical scoring failed to distinguish patients with symptomatic lower extremity osteoarthritis (OA) from healthy controls in each component of the assessment. However, principal component analysis of shape models generated from MMC recordings revealed significant differences in subject posture between the OA and control cohorts for six of the eight components. Additionally, time-series models of subject posture change over time revealed distinct movement patterns and reduced overall postural change in the OA cohort compared to the controls. Finally, a novel metric quantifying postural control was derived from subject specific kinematic models and was shown to distinguish OA (1.69), asymptomatic postoperative (1.27), and control (1.23) cohorts (p = 0.0025) and to correlate with patient-reported OA symptom severity (R = -0.72, p = 0.018). Time series motion data have superior discriminative validity and clinical utility than conventional functional assessments in the case of the SEBT. Novel spatiotemporal assessment approaches can enable routine in-clinic collection of objective patient-specific biomechanical data for clinical decision-making and monitoring recovery.

HIV Symptom Clusters are Similar Using the Dimensions of Symptom Occurrence and Distress

ContextPeople living with HIV infection (PLWH) in the United States continue to experience a high symptom burden despite improvements in antiretroviral therapy. ObjectivesThe purpose of this study was to determine if the number and types of symptom clusters differed based on whether symptom occurrence rates or distress ratings were used to create the clusters. MethodsData from 2,000 patients with complete symptom occurrence rates and distress scores on the 20-item HIV Symptom Index from their first ambulatory clinic visit at one of six national HIV centers of excellence in the Center for AIDS Research Network of Integrated Clinical Systems were used in these analyses. Exploratory factor analysis was used to create the symptom clusters. ResultsThe same four symptom clusters (i.e., gastrointestinal, psychological, pain, body image) were identified using occurrence rates and distress ratings. For both dimensions of the symptom experience, the psychological, pain, and body image clusters each had the same symptoms. For the gastrointestinal cluster, four symptoms loaded on the occurrence dimension and six symptoms loaded on the distress dimension. ConclusionThe number and types of symptom clusters were relatively similar across the occurrence and distress dimensions of the symptom experience. Symptom clusters in PLWH may provide insights into the development of targeted interventions for multiple co-occurring symptoms.

Patient generated health data: Benefits and challenges

Patient Generated Health Data (PGHD) is defined as data generated by and from patients.1 The use of PGHD has rapidly increased with the widespread availability of smart phone mobile health applications (mHealth apps) and wearable devices. Currently, the vast majority of PGHD is generated via the use of mHealth apps and wearables like "Fitbit" or medical devices such as a continuous glucose monitoring device. There are many benefits of PGHD including increased monitoring of children's chronic health conditions outside clinical care to supplement ambulatory clinic visits, improved health outcomes, increased patient awareness and engagement and improved patient-provider communication. When leveraged properly, PGHD can be a powerful tool in delivering safe, effective, patient centered, efficient and equitable care as outlined by the Institute of Medicine (IOM).2 The challenges that limit collection, use and acceptance of PGHD include limited access to the internet, inability to incorporate PGHD into clinical workflows, data privacy and security concerns and apprehension about accuracy and safety of mHealth apps. These issues can lead to a lack of use or compliance with devices or apps associated with PGHD. To ensure optimal health benefits, agreement to leverage PGHD should be a joint decision between the clinician and the patient/caregiver. Future steps to ensure safety and clinical relevance of PGHD include involving regulatory authorities, device manufacturers and professional bodies to develop standards for mHealth apps and wearables to promote uncomplicated PGHD integration into workflows, easy and secure sharing of PGHD. Wearable technology, medical devices and smart phone apps become more advanced and widespread among the population, there will be an increasing potential for PGHD to facilitate personalized, efficient, and collaborative care resulting in improved health outcomes for children and adolescent and young adult. More research and innovation is needed to facilitate this transition.

P541 Efficacy, efficiency and aceptability of telemedicine for inflammatory bowel disease patients follow-up care during the COVID-19 pandemic lockdown

BackgroundDuring COVID-19 pandemic, numerous initiatives have been established to reduce disease transmission but ensure care for patients with inflammatory bowel disease (IBD). Ambulatory clinic visits were replaced by the implementation of telehealth modalities in most of IBD units during the pandemic lockdown. However, the efficacy, efficiency, and patient′s acceptability of using telemedicine by telephone consultation has not been evaluated.MethodsA prospective cohort study was performed in IBD patients who underwent telephone consultation during lockdown due to COVID-19 pandemic between 16th march and 13th April 2020. To assess the efficacy of this telephone consultation (COVID-visit), change in disease′s activity and treatment, non-scheduled visits, emergency consultation, hospital admission and non-elective surgery from COVID-visit to the next scheduled consultation (postCOVID-visit) were checked. To evaluate efficiency, the time period between COVID-visit and postCOVID-visit were compared with previous consultation (preCOVID-visit). Only patients with a confirmed diagnosis of IBD, regular follow-up in our IBD unit and with full available requested test results were included. A telephone survey was designed (5 questions) and conducted in all patients to rate satisfaction for using telemedicine.ResultsOut of a total of 274 patients, 220 patients (52.2% male; mean age 49±16 years; crohn′s disease n=126/ ulcerative colitis n=83/ indeterminate colitis n=11) were included. During the COVID-visit 41% patients were using biologic agents, 15% had active disease and 6.8% changed treatment (40% initiated corticosteroids; 30% started immunomodulators or biologic agents; 30% upgraded usual treatment). Only 1 patient consulted at the emergency department, 11 patients needed to rearrange the visit and none patient underwent surgery before the scheduled post-COVID visit. The interval to post- COVID visit compared to pre-COVID visit was reduced in 28.6%, remained equal in 33.6% and increased in 37.7% of patients. The satisfaction survey (n=185) revealed that 81.1% patients rated care as excellent, 94.6% perceived it was effective and solved doubts in 96.2% of patients. However, 44.4% of patients rather prefer on-site consultation for follow-up and only 52% considered that incorporating video would improve care.ConclusionTelemedicine care during the lockdown and despite been abruptly and rapidly implemented in IBD units, shows to be effective and efficient to care IBD patients. In addition, telephone consultation is well accepted by patients for short follow-up periods. Further follow-up studies should be carried out to determine the patient profile that will benefit most from this monitoring.

Patient Use and Clinical Practice Patterns of Remote Cardiology Clinic Visits in the Era of COVID-19

The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits. To understand whether the transition to remote visits is associated with disparities in patient use of care, diagnostic test ordering, and medication prescribing. This cross-sectional study used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County, California, during 2 periods: April 1, 2019, to December 31, 2019 (pre-COVID) and April 1 to December 31, 2020 (COVID-era). Statistical analysis was performed from January to February 2021. In-person or remote ambulatory cardiology clinic visit at one of 31 during the pre-COVID period or COVID-era period. Comparison of patient characteristics and frequencies of medication ordering and cardiology-specific testing across 4 visit types (pre-COVID in-person (reference), COVID-era in-person, COVID-era video, COVID-era telephone). This study analyzed data from 87 182 pre-COVID in-person, 74 498 COVID-era in-person, 4720 COVID-era video, and 10 381 COVID-era telephone visits. Across visits, 79 572 patients were female (45.0%), 127 080 patients were non-Hispanic White (71.9%), and the mean (SD) age was 68.1 (17.0) years. Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic individuals (24 934 pre-COVID in-person visits [28.6%] vs 19 742 COVID-era in-person visits [26.5%] vs 3633 COVID-era video visits [30.4%] vs 1435 COVID-era telephone visits [35.0%]; P < .001 for all comparisons), have private insurance (34 063 pre-COVID in-person visits [39.1%] vs 25 474 COVID-era in-person visits [34.2%] vs 2562 COVID-era video visits [54.3%] vs 4264 COVID-era telephone visits [41.1%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone), and have cardiovascular comorbidities (eg, hypertension: 37 166 pre-COVID in-person visits [42.6%] vs 31 359 COVID-era in-person visits [42.1%] vs 2006 COVID-era video visits [42.5%] vs 5181 COVID-era telephone visits [49.9%]; P < .001 for COVID-era in-person vs telephone; and heart failure: 14 319 pre-COVID in-person visits [16.4%] vs 10 488 COVID-era in-person visits [14.1%] vs 1172 COVID-era video visits [24.8%] vs 2674 COVID-era telephone visits [25.8%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone). After adjusting for patient and visit characteristics and in comparison with pre-COVID in-person visits, during video and telephone visits, clinicians had lower odds of ordering any medication (COVID-era in-person: odds ratio [OR], 0.62 [95% CI, 0.60-0.64], COVID-era video: OR, 0.22 [95% CI, 0.20-0.24]; COVID-era telephone: OR, 0.14 [95% CI, 0.13-0.15]) or tests, such as electrocardiograms (COVID-era in-person: OR, 0.60 [95% CI, 0.58-0.62]; COVID-era video: OR, 0.03 [95% CI, 0.02-0.04]; COVID-era telephone: OR, 0.02 [95% CI, 0.01-0.03]) or echocardiograms (COVID-era in-person: OR, 1.21 [95% CI, 1.18-1.24]; COVID-era video: OR, 0.47 [95% CI, 0.42-0.52]; COVID-era telephone: OR, 0.28 [95% CI, 0.25-0.31]). Patients who were Asian, Black, or Hispanic, had private insurance, and had at least one of several cardiovascular comorbidities used remote cardiovascular care more frequently in the COVID-era period. Clinician ordering of diagnostic testing and medications consistently decreased when comparing pre-COVID vs COVID-era and in-person vs remote visits. Further studies are needed to clarify whether these decreases represent a reduction in the overuse of tests and medications vs an underuse of indicated testing and prescribing.

Characteristics of Non-Spine Musculoskeletal Ambulatory Care Visits in the United States, 2009-2016.

Despite the enormous economic and societal impact of musculoskeletal disorders, detailed data on the patient demographics and visit characteristics of nonspine musculoskeletal ambulatory care are sparse. Such data are essential to inform policymakers on population health needs and to justify health care resource allocation. To determine the demographic, patient, and visit characteristics of adult musculoskeletal ambulatory clinic visits, with the exception of spine visits, in the United States. Survey/registry. National Ambulatory Medical Care Survey (NAMCS), Centers for Disease Control and Prevention (CDC) 2009 to 2016. The NAMCS was designed to capture information regarding the provision and use of ambulatory medical care services in the United States. Nonfederally employed office-based physicians reported data for this survey from 2009 to 2016. None. Average annual estimated number (in 100 000s), Average annual estimated rate of ambulatory care musculoskeletal visits per 100 U.S. adults. During 2009 to 2016, the leading cause of musculoskeletal visits was knee symptoms (15.3 million annually from 2009 to 2010, 14.0 million annually from 2011 to 2012, 12.5 million annually from 2013 to 2014, and 12.4 million annually from 2015 to 2016). Musculoskeletal visits were most frequent in patients that were 45 to 64 years of age (40.4% to 43.6% of visits were for patients 45 to 64 years of age depending on body region). Orthopedic surgeons conducted more musculoskeletal visits than any other physician specialty for all body regions. Among body regions, magnetic resonance imaging (MRI) studies were ordered most commonly for patients with shoulder (total visits in 100 000 ± standard error [SE] 47.00 ± 0.21; 12.5% of total visits for shoulders) and knee symptoms (61.85 ± 0.15; 11.4% of total visits for knees). Opioid and opioid analgesic combinations (9.2% to 14.8% of visits) were most commonly prescribed in visits related to hip complaints. Visits were most frequent for knee symptoms and in patients of working age groups, which likely affects work productivity. Orthopedic surgeons were the most common provider specialty. Opioid medications were prescribed most commonly for patients with hip symptoms, which may highlight an area for potential intervention given the ongoing opioid crisis.

Group A Streptococcal Pharyngitis Testing Appropriateness in Pediatric Acute Care Settings.

Acute pharyngitis is one of the most common causes of ambulatory clinic visits; however, group A Streptococcus accounts for less than a third. National guidelines recommend against streptococcal testing in patients with viral features. This study aims to assess the rate of inappropriate streptococcal rapid antigen detection tests (RADT)s in children evaluated in urgent care clinics (UCC)s and emergency department (ED)s at a children's hospital. We retrospectively reviewed charts of 10% of children 3 years or older with RADTs ordered between April and September 2018 at EDs and UCCs. The test was determined to be inappropriate if the patient had no sore throat and/or had 2 or more viral symptoms: rhinorrhea/congestion, cough, diarrhea, hoarseness, conjunctivitis, or viral exanthem. Over the study period, 7678 RADTs were performed, of which 7024 (91.2%) were in children 3 years or older. We evaluated 708 charts and found 44% of RADTs were inappropriate. The predicted probability of inappropriate RADT was highest among patients with a triaged reason for visit for respiratory complaints (70.5%), viral upper respiratory tract infection (69.7%), and rash (61.3%). Of the inappropriate RADTs, 20.1% were positive, whereas 32.2% of the appropriate RADTs were positive. Quality improvement initiatives are needed to decrease the rate of inappropriate RADTs in pediatric UCC and ED settings.

Rotavirus Vaccine Is Effective Against Rotavirus Gastroenteritis Resulting in Outpatient Care: Results From the Medically Attended Acute Gastroenteritis (MAAGE) Study.

Rotavirus is a common cause of severe pediatric acute gastroenteritis. Two vaccines are licensed in the United States and have demonstrated high effectiveness against moderate to severe disease. However, fewer data are available on rotavirus vaccine effectiveness (VE) against milder disease. We leveraged active surveillance data from Kaiser Permanente Northwest to calculate rotavirus VE against medically attended rotavirus illness among age-eligible children. We utilized a test-negative case-control design and applied 4 distinct case definitions based on reverse transcription-quantitative real-time PCR (qRT-PCR) assay and enzyme immunoassay (EIA) test results. VE was calculated as 100 × (1 - odds ratio), and models were adjusted for age group. The VE analysis population comprised 842 children, 799 (95%) of whom had mild disease requiring at most a clinic visit and 698 (83%) of whom were fully vaccinated against rotavirus. Age-adjusted VE was 70% (95% confidence interval [CI], 37-86%) against disease defined solely by qRT-PCR results, 72% (95% CI, 31-89%) against disease as defined by qRT-PCR with a quantification cycle (C q ) value <27, 73% (95% CI, 32-90%) against disease that was qRT-PCR positive but EIA negative, and 62% (95% CI, -20-88%) against disease defined solely by EIA. Results were similar when restricting to disease resulting in at most an ambulatory clinic or emergency department visit. These results support the effectiveness of rotavirus vaccination in protecting US children from mild to moderate and severe disease. Our findings are also useful to show the effectiveness of rotavirus vaccination against qRT-PCR-defined illness.

Burden of Norovirus in the United States, as Estimated Based on Administrative Data: Updates for Medically Attended Illness and Mortality, 2001-2015.

Up-to-date estimates of the burden of norovirus, a leading cause of acute gastroenteritis (AGE) in the United States, are needed to assess the potential value of norovirus vaccines in development. We aimed to estimate the rates, annual counts, and healthcare charges of norovirus-associated ambulatory clinic encounters, emergency department (ED) visits, hospitalizations, and deaths in the United States. We analyzed administrative data on AGE outcomes from 1 July 2001 through 30 June 2015. Data were sourced from IBM MarketScan Commercial and Medicare Supplemental Databases (ambulatory clinic and ED visits), the Healthcare Utilization Project National Inpatient Sample (hospitalizations), and the National Center for Health Statistics multiple-cause-of-mortality data (deaths). Outcome data (ambulatory clinic and ED visits, hospitalizations, or deaths) were summarized by month, age group, and setting. Healthcare charges were estimated based on insurance claims. Monthly counts of cause-unspecified gastroenteritis-associated outcomes were modeled as functions of cause-specified outcomes, and model residuals were analyzed to estimate norovirus-associated outcomes. Healthcare charges were estimated by applying average charges per cause-unspecified gastroenteritis encounter to the estimated number of norovirus encounters. We estimate 900 deaths (95% confidence interval [CI], 650-1100), 109 000 hospitalizations (95% CI, 80 000-145 000), 465 000 ED visits (95% CI, 348 000-610 000), and 2.3 million ambulatory clinic encounters (95% CI, 1.7-2.9 million) annually due to norovirus, with an associated $430-$740 million in healthcare charges. Norovirus causes a substantial health burden in the United States each year, and an effective vaccine could have important public health impact.

Sex Disparities in Outpatient Management of Postlaminectomy Syndrome

Abstract INTRODUCTION Postlaminectomy syndrome (PLS), a major cause of chronic back pain following spinal surgery, is often managed with pharmacological (ie, opioid narcotics, NSAIDs, intraspinal injections) or surgical interventions (eg, spinal cord stimulation). Despite the burden of opioid-related overdose, abuse, and mortality especially in the setting of postprocedural analgesia, there exists a gap in current literature regarding sex differences in opioid prescriptions. This study investigates sex-related disparities in opioid prescriptions pertaining to PLS in a large national survey of ambulatory clinic visits. METHODS We extracted outpatient clinic visit data from the 2007 to 2016 National Ambulatory Medical Care Survey (NAMCS) (n = 126 males, n = 96 females) for patients who were seen for PLS. Variables collected included medications and potential covariates (age, race, insurance coverage, and medical history). Baseline patient characteristics were compared using Chi-square tests for nominal variables, and differences in means were compared using a two-tailed t-test (a = 0.05). RESULTS Males and females evaluated for PLS were similar at baseline with respect to age, race, medical history, and insurance except for Medicare coverage (26.19% of males vs 39.58% of females; P = .048). Despite similar baseline qualities, men had significantly higher rates of opioid prescription than women (76.19% vs 58.33%; 95% CI 1.07-1.59; P = .007). However, there were no differences in methadone maintenance therapy, NSAID, spinal cord stimulation, or intraspinal injection prescriptions. CONCLUSION Despite similar baseline characteristics, males with PLS were significantly more likely to be prescribed opioids compared to their female counterparts. This novel finding, which contrasts with established trends noting higher rates of opioid use in women, may result from physician bias or differing manifestations of PLS pain in men and women.

Cost Analysis of Drug-related Problems in Saudi Arabia: Patients’ and Healthcare Providers’ Perspective

Purpose: To explore the cost analysis of drug-related problems in Saudi Arabia from patient and healthcare provider’s perceptive. Methods: It is a 4-months cross-sectional survey of drug-related problem information in Saudi Arabia. The survey consisted of two-part demographic information, and second part consisted of thirteen questions focusing on general knowledge of drug-related problems, their occurrence, and costs. The questions divided into three domains. It included domain 1: Primary or essential information about knowledge and perception of drug-related problems, domain 2: The cost analysis of drug-related problems, domain 3: Clinical outcome of drug-related problems. The questions about the cost of drug-related problems, health insurance coverage and the economic outcome of those issues including pharmacy visit, ambulatory care clinic visit, an emergency visit, hospital admission, critical care admission, drug-induced death. The American Society of Health-System Pharmacist definitions of drug-related problems used. The survey distributed through social media by using what’s App to almost two thousand public and healthcare professionals overall Kingdom of Saudi Arabia. It analyzed domain two the cost analysis of drug-related problems through survey monkey system. Results: The total responders were one hundred and one. Of those 155 (77.9%) were patients while 44 (22.1%) were healthcare professionals. The gender distribution was female 180 (89.6%), and the male was 21 (10.4%). It is statistically non-significant (p Key words: Cost analysis, Drug-related problems, Patients, Healthcare providers, Perspective, Saudi Arabia.

Clinical Outcomes of Drug-related Problems in Saudi Arabia: Patients’ and Healthcare Providers’ Perspective

<p style="text-align: justify;"><strong>Purpose:</strong> To explore the patients and healthcare providers&rsquo; attitudes and perceptions on clinical outcomes drug-related problems in Saudi Arabia. <strong>Methods:</strong> It is a 4-months cross-sectional survey of drug-related problem information in Saudi Arabia. The study consisted of two-part a demographic data. The second part contained the questions about the frequent occurrence of drug-related problems, the type of medication-induced those problems, and the drug-related problem clinical consequences and outcomes. American Society of Health- System Pharmacist definitions of drug-related problems used. The 5-point Likert response scale system used. The survey distributed through social media. The questionnaire made of an electronic format, and it analyzed through survey monkey system. <strong>Results:</strong> The total responders were two hundred and one; the Saudi nationality was 188 (93.5%), and non-Saudi was 13 (6.5%) patient. The gender distribution was female 180 (89.6%), and the male was 21 (10.4%). The majority of them in age (18-44) 88% and located in Riyadh region 84 (41.8%) and Asir region 59 (29.4%). Of those 44 (22.1 %) were healthcare providers. The responders showed a high percentage of drug-related problem consequences and outcomes; drug-related problem lead to pharmacy visit was 59 (29.5%), additional tests were 47 (24.35%), ambulatory care clinic visit was 76 (38.4%), and an emergency visit was 43 (21.4%). The hospital admission was 46 (23.1%), general surgery 24 (11.9%), critical care admission was 24 (12.1%), and drug-induced death was 48 (24.12%). The most frequent drug-related problems occurred with the patient last year at least once; it was drug noncompliance 142 (71.4%), indications without medication 100 (50%), and adverse medication events 80 (40%). The most type of medicines induced the problems were Antibiotics, the drugs for pain, and dermatology drugs. <strong>Conclusion:</strong> Clinical outcome of drug-related problems occurred was potential. Clinical pharmacy services with emphasis to a drug-related program of antibiotics, painkiller dermatology medications are necessary. Moreover, to patient counseling program in health institutions and public awareness of medications is required in Saudi Arabia. <p style="text-align: justify;"><strong>Key words:</strong> Clinical outcomes, Drug-related problems, Patients, Healthcare providers, Perspective, Saudi Arabia.

A cohort study of a general surgery electronic consultation system: safety implications and impact on surgical yield

BackgroundElectronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case).MethodsRetrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014. Electronic consultation requests were reviewed for the presence/absence of consult domains: symptom acuity/severity, diagnostic evaluation, concurrent medical conditions, and attempted diagnosis. Logic regression was used to examine the association between completeness of consult requests and scheduling an ambulatory clinic visit. Surgical yield was also calculated, as was the percentage of patients requiring unanticipated healthcare visits.ResultsIn 2014, 1743 electronic consultations were submitted to general surgery. Among the 150 abstracted, the presence of consult domains ranged from 49% to 99%. Consult completeness was not associated with greater likelihood of scheduling an ambulatory visit. Seventy-six percent of consult requests (114/150) were scheduled for a clinic appointment and surgical yield was 46%; without an eConsult system, surgical yield would have been 35% (p=0.07). Among patients not scheduled for a clinic visit (n=36), 4 had related unanticipated emergency department visits.ConclusionEconsult systems can be used to safely optimize the surgical yield of a safety-net general surgery service.

Patient Satisfaction with Collection of Patient-Reported Outcome Measures in Routine Care.

Systematic collection of patient-reported outcome measures (PROMs) during ambulatory clinic visits can enhance communication between patient and provider, and provide the ability to evaluate outcomes of care. Little is known about patient satisfaction of PROM data collection in routine clinical care. To evaluate patient reaction to the routine collection of PROMs in the ambulatory setting. Before all ambulatory clinic visits at our neurological institute, patients electronically complete health status questionnaires. We administered an 8-question patient satisfaction survey to a sample of patients seen across the institute after their clinical visit. Of 343 patients approached, 323 agreed to participate. The majority responded that the questionnaire system was easy to use, was an appropriate length, and benefited their care overall (strongly agree or agree=92.3%, 87.6%, and 77.3%, respectively). Provider review of the PROMs with the patient during the clinic visit was associated with significantly higher positive responses to all questions, even those regarding logistical aspects of the collection process. There were significant age and race differences in response to perceived benefit: those in the Black/other race category had a markedly lower probability of viewing the process favorably with increasing age. Systematic collection of PROMs via an electronic questionnaire appears to be well accepted by patients. A minority of patients did not feel the questionnaire content applied to their appointment or that the system was a beneficial feature of the clinical practice. The provider can significantly improve the patient's perception of PROM collection and the patient-physician encounter by reviewing the questionnaire results with the patient.