Ambulatory Clinic Research Articles

Physicians' and advanced practice providers' perceptions of the impact of embedded clinical pharmacists on the work environment in ambulatory care clinics.

Clinical pharmacists are recognized as valuable team members in primary care clinics due to the variety of patient care services they provide. This study examined nonpharmacist healthcare providers' perceptions of how embedded clinical pharmacists impact the work environment in ambulatory care clinics. This was an exploratory mixed methods study consisting of semistructured interviews and a subsequent survey. Participants included attending and resident physicians, and advanced practice providers (APPs) practicing in clinics with an embedded clinical pharmacist. Coded interview transcripts were analyzed to identify themes that were used to develop a survey. Interview participants were not asked to complete the survey. Survey responses were analyzed utilizing descriptive statistics. Subgroup analysis assessed for differences in responses based on provider type, gender, clinical practice area, years of practice, and pharmacy services utilization. Fourteen physicians and APPs participated in the semistructured interviews, and 43 other providers completed the survey. In the interviews, participants stated the clinical pharmacist contributed positively in terms of work environment, workload, work-related stress, and burnout. The major themes identified were sharing patient care responsibilities, saving provider time, and being a knowledgeable resource. Survey responses were consistent with interview statements; however, the positive impact differed between nonusers and moderate to high utilizers of clinical pharmacy services. The main barrier to collaborating with clinical pharmacists was their limited availability. Embedded clinical pharmacists positively impact the work environment in ambulatory care clinics by reducing provider workload, work-related stress, and burnout. Participants also noted clinical pharmacists are a trusted resource for patient care and drug information questions.

Prevalence and associated factors of medication-related problems among epileptic patients at ambulatory clinic of Mettu Karl Comprehensive Specialized Hospital: a cross-sectional study

BackgroundDespite appropriate treatment of epilepsy, the treatment outcome is poor in developing country. Therefore, the study was aimed to identify the magnitude and associated factors of epileptic patients at ambulatory clinic of south western Ethiopian hospital.MethodsA hospital-based cross-sectional study was conducted on epileptic patients who had follow-up at Mettu Karl Comprehensive Specialized Hospital (MKCSH). Data collection was done through patient interview and medical charts review. The pharmaceutical care network Europe foundation classification system was used to assess the drug therapy problem and Naranjo algorithm of adverse drug reaction was employed to identify the probability of adverse drug reaction. The data were analyzed by SPSS version 23 after data were entered by Epidemiological Information (Epi Info) 7.2.1. The multivariable logistic regressions were utilized and P < 0.05 was used to declare association.ResultsOver the study period, more than half of the participants 172(57.7%) were males. The magnitude of drug-related problems was found to be 164(55.0%). Among epileptic patients about 323 drug-related problems (DRPs) were identified on average, 1.084 drug-related problems (DRPs) per patient. The widely occurred types of drug-related problems were needs additional drug therapy 72(22.29%), dose too low 52(16.09%) and dose to high which accounts 50(15.48%). Regarding the predictors of drug-related problems, being a female (AOR = 3.57, 95% CI:1.85–6.88, P ≤ 0.001), having frequent seizures (AOR = 2.47, 95% CI%:1.33–4.61, P = 0.004) and the presence of poly-pharmacy (AOR = 3.57, 95% CI: 1.49–8.5, P = 0.004) were predictors of drug-related problems.ConclusionMore than half of the patients had a drug therapy problem. Number of medications taken by the patients, gender and the seizure frequency had a significant association with occurrence of drug therapy problems (DTPs). Therefore, the pharmaceutical care in general and drug information services in particular should be established to hinder any undesirable medication effects in our study area.

334 FASTTRAX - A FRACTURE RESPONSE SERVICE FOR NURSING HOME RESIDENTS

Abstract Background Nursing Home Residents (NHR) are the frailest group of older people and require a gerontologically attuned approach to care. The new FastTrax fracture response service has been developed as a result of a Quality Improvement (QI) project to evaluate the need for this service. The data leading to the development of this pathway is presented here. FastTraX ensures NHR receive optimal orthopaedic and gerontological care without necessity for emergency department (ED) presentation. Methods A retrospective, medical chart review was completed on all NHRs who presented over12-months to a level-4 hospital ED following a fall/injury. Included patients were nursing home residents with suspected fracture discussed with the on-call orthopaedic service. Patients who required more complex imaging other than plain film or with known/suspected head trauma were excluded. Data collected included demographics, clinical and imaging details, and care outcomes. Results In 2021, there were sixty-nine (mean age 80.3, 82.6% female) NHR presentations to the ED with fracture/ injury where orthopaedic opinion was sought following x-ray. Just-under half, 49.2 % (34/69) of patients were admitted, all of whom had confirmed fractures. However, 32.3% (11/34) of admitted NHRs were conservatively treated with an average length-of-stay of 3.6 days before discharge to NH. 6/34 (17.6%) of admitted NHRs died, and 5 of those deaths occurred post-operatively. Of the 50.7% (35/69) discharged directly back to NH from ED, 45.7% (16/35) of those had no fracture, whereas 54.2% (19/35) were discharged for conservative management. Therefore, potentially only 29/69 (33%) ED presentations required definitive orthopaedic/gerontological intervention necessitating admission and two-thirds are potentially avoidable. Conclusion The new FastTraX fracture response service is an Advanced-Nurse Practitioner (rANP) co-ordinated integrated service combining use of on-site mobile radiological diagnostics in the NH, a fast-track ambulatory orthopaedic-consult clinic, and specialist gerontological care delivered in timely response to support NH staff in avoiding ED transfer where appropriate.

Looking into the Laboratory Staffing Issues that Affected Ambulatory Care Clinical Laboratory Operations during the COVID-19 Pandemic.

Our New York City Municipal Public Health System-based multisite ambulatory and school-based Gotham Health clinics offer waived point-of-care tests and provider-performed microscopy to the local communities. Our Gotham Health laboratory service conducts system-wide centralized implementation, monitoring, and oversight of the POCT operations. Laboratory staffing has always been an issue for us as there is a decades-long shortage of laboratory staff, primarily licensed medical technologists and technicians, in New York, like many other states. Our clinical laboratory operations team struggled to hire qualified people even before the COVID-19 pandemic onset. It has faced more significant challenges with the emergence of SARS-CoV-2 pandemic cases in New York City and across the country since mid-March 2020. As staffing continues to be a struggle, it directly affected the POCT performances and a system-wide reduction in the test numbers during the pandemic. We investigated to identify the factors that made staffing more challenging. The impact on our POCT started after laboratory staff relocated to the acute care hospital laboratories to provide testing support during the pandemic's peak. That caused significant delays or complete cessation of POCT operations in the clinics due to a lack of oversight support. We also experienced the risk of more vacated positions where staff already feel overworked, overwhelmed, and emotionally drained, causing professional burnout. The significant challenges identified are noncompliance with vaccine mandates resulting in job dismissal and voluntary resignations in exchange for higher-paying laboratories. Finally, the other challenges identified were frequent sick calls due to mental fatigue, retirement of seasoned staff, and inability to attract qualified technologists to meet the demands of increasing test-ordering patterns. Determining the factors that culminated in the staffing issues becoming more challenging during the COVID-19 pandemic in our ambulatory care clinic laboratory operations will help us in future crisis planning and mitigation.

301 BENEFITS OF ENVIRONMENTAL MUSIC THERAPY IN AN ACUTE HOSPITAL

Abstract Background Environmental Music Therapy (EMT) uses live music played by a music therapist to enhance the surrounding environment and is increasingly used in clinical settings. Studies show that EMT may reduce anxiety, enhance wellbeing, promote better communication between patients and staff, and reduce patient perception of waiting times in hospital. We aimed to explore the benefit of EMT for older adults in a geriatric outpatient setting and on rehabilitation wards. Methods Harp music was played by a music therapist in the vicinity of ambulatory clinics and on rehabilitation wards for 4 hours per week (over a 2-day period) for 20 weeks. Music exposure on any given day was to an estimated 50 outpatients, as well as 50 people passing the vicinity or to about 30 patients on the rehabilitation ward. Music was selected and played in a dynamic process, responding to verbal and non-verbal reactions of patients, family, and staff. Voluntary responses were recorded and collated. Results There were 36 recorded responses and all reflected positively on EMT. Patients cited that the music created a welcoming space and stimulated interaction and conversation. Several patients waiting for their clinic appointment noted that it distracted from fearful expectation and was a source of comfort. Some commented that they felt more relaxed and that it reduced stress. On rehabilitation wards, patients found familiar music to be calming with nurses citing that it stimulated social interaction between patients, family and staff. Responses to EMT gave insights that resulted in patient referrals for music therapy. Conclusion Environmental music played by a music therapist was found to modify patient hospital experiences. In particular, it appeared to reduce self-perceived stress and stimulate positive social interaction and conversation. This supports the use of EMT to advance the integration of the arts for wellbeing in an acute hospital.

The impact of an early intervention home-based program on body composition in preterm-born preschoolers with very low birth weight.

Early child interventions focused on the family prevented neurodevelopmental and behavioral delays and can provide more knowledge regarding responsive feeding, thus creating learning opportunities to promote better quality nutrition and preventing failure to thrive. The aim is to verify the impact of a continuous program of early home-based intervention on the body composition of preschool infants who were born preterm with very low birth weight (VLBW). This is a longitudinal analysis from a randomized controlled trial, including VLBW preterm children, born in a tertiary hospital in Southern Brazil and followed up at the high-risk institutional ambulatory clinic. Participants were divided into the intervention group (IG): skin-to-skin care with the mother (kangaroo care), breastfeeding policy, and tactile-kinesthetic stimulation by mothers until hospital discharge. Subsequently, they received a program of early intervention with orientation and a total of 10 home visits, independently from the standard evaluation and care that was performed following the 18 months after birth; conventional group (CG): standard care according to the routine of the newborn intensive care unit (NICU), which includes kangaroo care, and attending to their needs in the follow-up program. Body composition estimation was performed using bioelectrical impedance analyses (BIA), and physical activity and feeding practices questionnaires were evaluated at preschool age, as well as anthropometric measurements and biochemical analysis. Data of 41 children at 4.6 ± 0.5 years old were evaluated (CG n = 21 and IG n = 20). Body weight, height, body mass index, waist and arm circumferences, and triceps and subscapular skinfold did not differ between groups. The IG presented higher segmented fat-free mass (FFM) when compared to the CG (right arm FFM: 0.74 vs. 0.65 kg, p = 0.040; trunk FFM: 6.86 vs. 6.09 kg, p = 0.04; right leg FFM: 1.91 vs. 1.73 kg, p = 0.063). Interaction analyses showed that segmented FFM and FFM Index were associated with higher iron content in the IG. In the CG, interaction analyses showed that increased visceral fat area was associated with higher insulin resistance index. An early intervention protocol from NICU to a home-based program performed by the mothers of VLBW preterm children of low-income families presents a small effect on FFM.

Use of a remote telemonitoring platform significantly improves medication optimisation in heart failure patients

Abstract Background Guideline directed medical therapy (GDMT) has been shown to reduce morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). Despite this, a large number of eligible patients do not receive these treatments or have prolonged delays in achieving optimal doses. Purpose To determine whether a telemonitoring-supported, remote medication optimisation programme could increase the proportion of HFrEF patients reaching maximum tolerated GDMT, in a shorter period of time compared to usual care. Methods A prospective, randomised controlled trial recruited 108 patients with a diagnosis of HFrEF from the ambulatory heart function clinic of a North American cardiac centre. All patients were enrolled onto a non-invasive remote monitoring platform which allowed daily nurse coordinator-led assessment of patient-reported symptoms and trends in heart rate, blood pressure and weight. In the remote titration intervention group, telemonitoring data were used by treating physicians to make decisions on optimisation of GDMT every two weeks, which was enacted by the patient's nurse coordinator, with no physician visit required. Patients in the control group were reviewed in clinic by their treating physician, where medication doses were optimised as per standard of care. The proportion of patients achieving maximum tolerated GDMT, and the time taken for this were compared between groups. Continuous data are presented as mean±standard deviation and compared with Student's t-test, while categorical data are shown as number (%) and compared using the Chi-squared test. Results 108 patients (69.4% male, mean age 54.1±15.4 years) were recruited with a median follow-up of 740 days. Baseline characteristics and medication prescription were similar between groups (56 randomised to remote titration, RT, 52 to usual care, UC, see Table). There were three withdrawals from the RT group and two from the UC group. Significantly more patients in the RT group 52/53 (98.1%) achieved the primary outcome, reaching maximum tolerated GDMT, compared with 42/50 (84.0%) in the UC group (p=0.01). The RT group achieved GDMT earlier (123±70 vs. 183±136 days, p=0.01) with a 40% reduction in clinic visits (p&amp;lt;0.01). In a time-to-event analysis, time to optimisation was significantly shorter in the intervention group (median 105 vs. 165 days, p[log rank] &amp;lt;0.01, see Figure). There was a similar increase in prescription of GDMT in both groups and no differences in hospitalisation or urgent clinic review suggesting that there was no excess hazard of remote titration. Conclusion Remote titration of GDMT in HFrEF patients resulted in more patients achieving maximum tolerated doses, on average two months earlier, with a reduction in clinic visits and no excess adverse outcomes. Telemonitoring-supported remote GDMT titration is effective, safe and could reduce healthcare costs associated with the management of HFrEF. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): DHB is supported by a post-doctoral fellowship award from TRANSFORM-HF (Ontario, Canada).

THE STATE OF HEART FAILURE SERVICES IN CANADA: FINDINGS OF THE HEART &amp; STROKE NATIONAL HEART FAILURE RESOURCES AND SERVICES INVENTORY

THE STATE OF HEART FAILURE SERVICES IN CANADA: FINDINGS OF THE HEART &amp; STROKE NATIONAL HEART FAILURE RESOURCES AND SERVICES INVENTORY

ADHERENCE TO GUIDELINE-DIRECTED MEDICAL THERAPY AMONG PATIENTS FOLLOWED AT AN AMBULATORY HEART FUNCTION CLINIC

ADHERENCE TO GUIDELINE-DIRECTED MEDICAL THERAPY AMONG PATIENTS FOLLOWED AT AN AMBULATORY HEART FUNCTION CLINIC

S1431 Hepatitis B Vaccination Rates in Ambulatory Patients With Chronic Liver Disease Before and After the Onset of the COVID-19 Pandemic

Introduction: Hepatitis B (HBV) is one of the most prevalent infectious diseases worldwide. It is preventable with vaccination and experts recommend screening for HBV immunity in all patients with chronic liver disease. The 2019 novel coronavirus (COVID-19) pandemic disrupted ambulatory care clinics throughout the United States, interfering with normal vaccination screening and administration. In the subsequent years after the pandemic began, clinicians and patients alike have had to play catch up on healthcare maintenance. This study was done to determine if the rate of screening and vaccination of patients with chronic liver disease for Hepatitis B changed in the subsequent years after the onset of the COVID-19 pandemic at our single institution. Methods: A retrospective study was performed from January 2000 to January 2019 and from February 2022 to April 2022 on patients seen in the ambulatory clinic of our community-based hospital. The criteria to be vaccinated for Hepatitis B was patients with chronic liver disease (defined as cirrhosis, nonalcoholic fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and transaminitis (ALT or AST >2x ULN) not immune to HBV. Seven-hundred-and-ninety patients were selected from the first period and eighty-six patients were selected from the second period. Results: We found that there were increases in the rate of screening for HBV immunity as well as the rate of vaccination against HBV in the post-COVID onset years compared to the pre-COVID onset years. (Table) Conclusion: We believe that the increases in both screening rates and subsequent vaccination are due to both patient and physician driven motives. Our patients are requesting re-evaluation of vaccination history with increased compliance in vaccination course. We have also noticed a more thorough review of patient history by our physicians, focusing on what was missed during the years since the onset of the pandemic. Further studies qualifying these observations are underway, however, we believe it is important to present these results now to demonstrate that we can continue to improve the care we provide in the outpatient setting despite the pandemic. In fact, the COVID-19 pandemic itself may have improved the overall care we provide for patients. Table 1. - Rates of Screening and Subsequent Vaccination Against Hepatitis B Virus in Patients With Chronic Liver Disease Before and After the Onset of COVID-19 Pre-COVID Onset Post-COVID Onset Percent Change Screening for HBV Immunity 88.5% 94.2% +6.4% Rate of 1st HBV Vaccine Given 46.1% 63.5% +37.7% Rate of 2nd HBV Vaccine Given 37.5% 48.3% +28.8% Rate of 3rd HBV Vaccine Given 27.5% 28.8% +4.7%

Care teams misunderstand what most upsets patients about their care

BackgroundNegative healthcare delivery experiences can cause lasting patient distress and medical service misuse and disuse. Yet no multi-site study has examined whether care-team members understand what most upsets patients about their care. MethodsWe interviewed 373 patients and 360 care-team members in the medical oncology and ambulatory surgery clinics of 11 major healthcare organizations across six U.S. census regions. Patients deeply upset by a service-related experience (n = 99, 27%) answered questions about that experience, while care-team members (n = 360) answered questions about their beliefs regarding what most upsets patients. We performed content analysis to identify memorably upsetting care (MUC) themes; a generalized estimating equation to explore whether MUC theme mention frequencies varied by participant role (care-team member vs. patient), specialty (oncology vs. surgery), facility (academic vs. community), and gender; and logistic regressions to investigate the effects of participant characteristics on individual themes. ResultsMUC themes included three systems issues (inefficiencies, access barriers, and facilities problems) and four care-team issues (miscommunication, neglect, coldness, and incompetence). MUC theme frequencies differed by role (all Ps < 0.001), with more patients mentioning care-team coldness (OR = 0.37; 95% CI, 0.23-0.60) and incompetence (OR = 0.17; 95% CI, 0.09-0.31); but more care-team members mentioning system inefficiencies (OR = 7.01; 95% CI, 4.31–11.40) and access barriers (OR, 5.48; 95% CI, 2.81–10.69). ConclusionsWhen considering which service experiences most upset patients, care-team members underestimate the impact of their own behaviors and overestimate the impact of systems issues. ImplicationsHealthcare systems should reconsider how they collect, interpret, disseminate, and respond to patient service reports. Level of evidenceLevel III.

2.6 Clinical Interventions for Adolescent Vaping of Nicotine and Cannabis

The use of vapes or electronic cigarettes to consume nicotine and cannabis continues to be a major health concern in the pediatric age group. Recent studies show that 1 in 5 high school students in the United States have vaped nicotine in the past month and that vaping of cannabis has doubled among US and Canadian adolescents between 2013 and 2020. The limited evidence for the use of medications to treat nicotine and cannabis is a barrier to effective treatment. This lecture will discuss clinical interventions for cessation of nicotine and cannabis use via vapes and will provide practical considerations from experience in ambulatory and inpatient clinic settings.

There’s no place like home: Home time among older adults with AML by therapy intensity.

376 Background: Older adults with acute myeloid leukemia (AML) have identified home time (HT) as a critical outcome influencing their treatment selection. However, few studies have characterized HT in this disease setting. Methods: We conducted a retrospective, observational study of adults age ≥60 diagnosed with AML from 2015 to 2020 at University of North Carolina Health. First-line therapy was classified by intensity: low (hypomethylating agent [HMA]), intermediate (HMA+Venetoclax), and high (anthracycline-based). The primary outcome was cumulative HT days from time of diagnosis. A day was defined as HT if an individual was not hospitalized and did not utilize emergency department services or ambulatory oncology clinics. Secondary outcomes were proportion of days at home (PDH) and overall survival (OS). Covariates included demographics and disease risk by ELN 2017 criteria. HT was evaluated via summary statistics with comparisons among treatment groups made via linear (for HT / PDH) or Cox proportional hazard (for OS) regression models adjusted for age &amp; ELN risk. PDH was further adjusted for log of follow up time. Median OS was calculated via the Kaplan-Meier method. Results: 197 individuals were identified. Mean age was 71 (range 60-95), 79% were white, and 59% male. 38% received high-intensity therapy, 33% received low, and 29% intermediate. Mean age was lower in the high-intensity group (66 vs 74 in low, 75 in intermediate; Kruskal-Wallis p &lt; 0.0001). Mean HT was 284 days, and median survival was 10.3 months (95% CI 8.4-12.7). Mean HT was greater in the high-intensity group at 409 days (CI 310-508) vs. 243 (158-328) in low and 169 (121-216) in the intermediate group (Table). The high-intensity group had greater median OS at 19.9 months vs. 8.8 (low) or 7.7 (intermediate) but a lower mean adjusted PDH (high: 0.60 vs. low: 0.73 vs. intermediate: 0.75; p &lt; 0.0001). In adjusted models, these differences remained statistically significant. Mean HT, median OS, and mean adjusted PDH did not differ significantly between the low &amp; intermediate groups. Conclusions: Older adults with AML spend a tremendous amount of time - roughly 40% of days - engaged in oncology care. Although receiving high-intensity therapy was associated with longer OS, increases in HT were more modest, indicating that much of the survival gains were spent engaged in care. Shared treatment decision-making should incorporate patient preferences for securing HT versus attempting to prolong survival.[Table: see text]

S331 The Impact of PCP Counseling for Colorectal Cancer Screening: A Primary Care Quality Improvement Project

Introduction: Effective primary care physician (PCP) counseling plays a key role in patient adherence to primary prevention cancer screening programs. The impact of PCP counseling on the patients’ adherence to colorectal cancer (CRC) screening programs is believed to be underestimated. Therefore, we conducted a 24-week prospective quality improvement initiative investigating the effects of PCP counseling for CRC screening on patient participation rates. Methods: We identified patients who met the criteria for CRC screening during their routine primary care appointments at the resident-run internal medicine ambulatory clinic at Cleveland Clinic (CCF) from October 2021 to March 2022. A fishbone diagram was used for root-cause analysis which revealed key causes of inadequate CRC screening: lack of patient education and awareness about the importance of CRC screening. Our PDSA cycle included patient education by PCPs about the importance of CRC screening in asymptomatic patients and the benefits of early treatment of the disease. The PCPs explained various screening modalities. The chosen modality was ordered for interested patients. The primary outcomes were the percentage of patients who agreed to undergo CRC screening and the percentage of patients who scheduled or completed the screening test. Results: A total of 52 subjects both met the criteria for CRC screening and attended their routine primary care appointments at CCF where they underwent PCP counseling. Only 4 (8%) patients had undergone a prior CRC screening test. The median age was 55 years, and females compromised 52% of the subjects. A total of 44 subjects (85%) agreed to undergo CRC screening after being counseled by their PCPs. Of those 44 individuals, 42 (95%) chose colonoscopy, and two (5%) chose FOBT. By the end of the study period, eighteen patients (41%) had either scheduled or completed their tests (Figure, Table). Conclusion: Our study demonstrates that PCP counseling is associated with high patient engagement to undergo CRC screening. However, it is still unclear whether PCP counseling in the context of a primary care clinic visit alone is sufficient to ensure the completion of CRC screening. Thus, we plan to examine CRC screening completion rates within a year of the original test being ordered and explore barriers that limit the completion of CRC screening by surveying patients in subsequent clinic visits. We will propose other interventions (email reminders or phone calls) to address these barriers and improve CRC screening completion rates.Figure 1.: Time course of patients who agreed to undergo CRC screening. Table 1. - Summary of the data Age median (range) 55 (45-83) yrs Female vs. Male 52.0% vs 48.0% Percentage of patients were up to date with CRC screening 8.0% Percentage of patients who agreed to undergo CRC screening 85.0% Percentage of patients who scheduled their CRC screening test by the time of data curation 41.0%

64 Impact of Substance Use Navigators on Addiction Treatment and Outcomes for Emergency Department Patients in an Integrated Public Health System

64 Impact of Substance Use Navigators on Addiction Treatment and Outcomes for Emergency Department Patients in an Integrated Public Health System

Characteristics Associated with Burnout among Cardiologists in an Academic Medical Setting: Baseline Survey Results from a Communication Coaching RCT.

Objectives: Clinician burnout poses risks not just to clinicians but also to patients and the health system. Cardiologists might be especially prone to burnout due to performing high-risk procedures, having to discuss serious news, and treating diseases that incur significant morbidity and mortality. Few have attempted to examine which cardiologists might be at higher risk of burnout. Knowing at-risk cardiologists can help frame resilience interventions. Methods: We enrolled 41 cardiologists across five ambulatory cardiology clinics into a randomized controlled trial where we assessed the Maslach Burnout Inventory at baseline. We used bivariate analyses to assess associations between cardiologist demographics and burnout. Results: Cardiologists reported low burnout for depersonalization and personal accomplishment and moderate levels for emotional exhaustion. Female cardiologists reported emotional exhaustion scores in the “low” range (M = 12.3; SD = 10.06), compared to male cardiologists whose score was in the “moderate” range 19.6 (SD = 9.59; p = 0.113). Cardiologists who had greater than 15 years in practice reported higher mean scores of emotional exhaustion, indicating moderate burnout (M = 20.0, SD = 10.63), compared to those with less than 15 years in practice (M = 16.6, SD = 9.10; p = 0.271). Conclusions: In this sample, unlike prior studies, male cardiologists reported more burnout. Consistent with prior work, mid-level cardiologists might be at highest risk of emotional exhaustion.

Effectiveness of eHealth Self-management Interventions in Patients With Heart Failure: Systematic Review and Meta-analysis.

BackgroundHeart failure (HF) is a common clinical syndrome associated with substantial morbidity, a heavy economic burden, and high risk of readmission. eHealth self-management interventions may be an effective way to improve HF clinical outcomes.ObjectiveThe aim of this study was to systematically review the evidence for the effectiveness of eHealth self-management in patients with HF.MethodsThis study included only randomized controlled trials (RCTs) that compared the effects of eHealth interventions with usual care in adult patients with HF using searches of the EMBASE, PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL databases from January 1, 2011, to July 12, 2022. The Cochrane Risk of Bias tool (RoB 2) was used to assess the risk of bias for each study. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria were used to rate the certainty of the evidence for each outcome of interest. Meta-analyses were performed using Review Manager (RevMan v.5.4) and R (v.4.1.0 x64) software.ResultsIn total, 24 RCTs with 9634 participants met the inclusion criteria. Compared with the usual-care group, eHealth self-management interventions could significantly reduce all-cause mortality (odds ratio [OR] 0.83, 95% CI 0.71-0.98, P=.03; GRADE: low quality) and cardiovascular mortality (OR 0.74, 95% CI 0.59-0.92, P=.008; GRADE: moderate quality), as well as all-cause readmissions (OR 0.82, 95% CI 0.73-0.93, P=.002; GRADE: low quality) and HF-related readmissions (OR 0.77, 95% CI 0.66-0.90, P<.001; GRADE: moderate quality). The meta-analyses also showed that eHealth interventions could increase patients’ knowledge of HF and improve their quality of life, but there were no statistically significant effects. However, eHealth interventions could significantly increase medication adherence (OR 1.82, 95% CI 1.42-2.34, P<.001; GRADE: low quality) and improve self-care behaviors (standardized mean difference –1.34, 95% CI –2.46 to –0.22, P=.02; GRADE: very low quality). A subgroup analysis of primary outcomes regarding the enrolled population setting found that eHealth interventions were more effective in patients with HF after discharge compared with those in the ambulatory clinic setting.ConclusionseHealth self-management interventions could benefit the health of patients with HF in various ways. However, the clinical effects of eHealth interventions in patients with HF are affected by multiple aspects, and more high-quality studies are needed to demonstrate effectiveness.

Oral Chemotherapy Laboratory Monitoring and Follow-Up: A Review of the Literature.

There are many inefficiencies related to oral chemotherapy (OC) laboratory monitoring and follow-up in the ambulatory clinic setting. Patients with cancer prescribed OC have a higher risk of adverse events when there is inconsistent laboratory test result reporting and follow-up from their oncology provider. The aim of this article is to improve OC laboratory monitoring by identifying potential barriers and opportunities for reliable communication between patients and providers in the outpatient clinical setting. A literature review found 76 articles, of which 15 were selected for review. Six themes were synthesized and discussed. Healthcare systems use technology, standard pathways, and clear patient-provider communication following laboratory testing to ensure patient safety. Implementing and testing evidence-based solutions and structured frameworks to identify gaps in outpatient laboratory monitoring and follow-up can improve patient satisfaction and safety during OC treatment.

Assessing the proportion of patients with hepatitis C treated before and after initiation of an ambulatory pharmacist-led hepatitis C program: A retrospective analysis

BackgroundIn a community with rates of hepatitis C virus (HCV) 10 times greater than the national average, a pharmacist-led HCV clinic creates a unique opportunity to make an extensive impact on a large population. This study aimed to describe the impact of an ambulatory pharmacist-led HCV clinic on successful HCV treatment initiation. ObjectivesThe primary objective was to determine HCV treatment initiation before and after introduction of a pharmacist-led HCV clinic. Secondary objectives include identifying benefits of the clinic through barriers that exist pre-and postclinic, average time to HCV treatment initiation, and current and last known points of care in the treatment process. Practice descriptionThe ambulatory program was established in 2018 with a collaborative practice agreement with gastroenterologists in the health system, allowing for providers to refer patients to the pharmacy clinic for HCV medication initiation and monitoring. Practice innovationThrough maintaining relations with providers, the local health department, and emergency department staff, pharmacists aimed to connect more patients to HCV treatment. Clinical pharmacists work with patients to refer them to specialty pharmacies, ensuring quick treatment start and financial coverage. Evaluation methodsA single-center, retrospective chart review was conducted to assess treatment initiation in patients with a positive HCV antibody in 2016 (preclinic) or 2019 (postclinic). ResultsA statistically significant difference was found for the proportion of patients that started treatment before versus after clinic initiation (P < 0.001). For secondary objectives, a statistically significant difference was found between the number of patients who completed the treatment process in 2016 and those in 2019 (P < 0.001). The average time from diagnosis to treatment initiation was reduced from 66.75 weeks ± SD 13.22 in 2016 to 22.87 weeks ± SD 4.19 in 2019. ConclusionAn ambulatory pharmacist-led HCV clinic results in a higher proportion of patients starting treatment for hepatitis C, better linkage to care, and shorter treatment duration.

A home-based, multidisciplinary liver optimisation programme for the first 28 days after an admission for acute-on-chronic liver failure (LivR well): a study protocol for a randomised controlled trial

BackgroundAcute-on-chronic liver failure (ACLF) represents a rising global healthcare burden, characterised by increasing prevalence among patients with decompensated cirrhosis who have a 28-day transplantation-free mortality of 33.9%. Due to disease complexity and a high prevalence of socio-economic disadvantage, there are deficits in quality of care and adherence to guideline-based treatment in this cohort. Compared to other chronic conditions such as heart failure, those with liver disease have reduced access to integrated ambulatory care services. The LivR Well programme is a multidisciplinary intervention aimed at improving 28-day mortality and reducing 30-day readmission through a home-based, liver optimisation programme implemented in the first 28 days after an admission with either ACLF or hepatic decompensation. Outcomes from our feasibility study suggest that the intervention is safe and acceptable to patients and carers.MethodsWe will recruit adult patients with chronic liver disease from the emergency departments, in-patient admissions, and an ambulatory liver clinic of a multi-site quaternary health service in Melbourne, Australia. A total of 120 patients meeting EF-Clif criteria will be recruited to the ACLF arm, and 320 patients to the hepatic decompensation arm. Participants in each cohort will be randomised to the intervention arm, a 28-day multidisciplinary programme or to standard ambulatory care in a 1:1 ratio. The intervention arm includes access to nursing, pharmacy, physiotherapy, dietetics, social work, and neuropsychiatry clinicians. For the ACLF cohort, the primary outcome is 28-day mortality. For the hepatic decompensation cohort, the primary outcome is 30-day re-admission. Secondary outcomes assess changes in liver disease severity and quality of life. An interim analysis will be performed at 50% recruitment to consider early cessation of the trial if the intervention is superior to the control, as suggested in our feasibility study. A cost-effectiveness analysis will be performed. Patients will be followed up for 12 weeks from randomisation. Three exploratory subgroup analyses will be conducted by (a) source of referral, (b) unplanned hospitalisation, and (c) concurrent COVID-19. The trial has been registered with the Australian New Zealand Clinical Trials Registry.DiscussionThis study implements a multidisciplinary intervention for ACLF patients with proven benefits in other chronic diseases with the addition of novel digital health tools to enable remote patient monitoring during the COVID-19 pandemic. Our feasibility study demonstrates safety and acceptability and suggests clinical improvement in a small sample size. An RCT is required to generate robust outcomes in this frail, high healthcare resource utilisation cohort with high readmission and mortality risk. Interventions such as LivR Well are urgently required but also need to be evaluated to ensure feasibility, replicability, and scalability across different healthcare systems. The implications of this trial include the generalisability of the programme for implementation across regional and urban centres.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621001703897. Registered on 13 December 2021.WHO Trial Registration Data Set. See Appendix 1