Ambulatory Health Care Research Articles

Anticoagulation stewardship in the ambulatory settings of long-term care and rehabilitation - A multi-centric descriptive pilot study.

Anticoagulants have consistently emerged as the leading cause of adverse drug events in both inpatient and outpatient settings. While literature on anticoagulation stewardship programs (ACSP) exists for hospital settings, there is a paucity of data in long-term care and rehabilitation settings. Assess the feasibility of a pharmacist led ACSP in the ambulatory healthcare settings of long-term care facilities (LTC) and rehabilitation centers (RC). We conducted a prospective pilot project in 3 rehabilitation centers and 7 long-term care facilities. Patients were selected over 5months in 2023. Patient and anticoagulant prescription-related characteristics were collected. The primary feasibility outcome was the proportion of anticoagulant prescription reviews leading to a pharmacist intervention. A total of 411 patients were enrolled. Common indications for anticoagulants were atrial fibrillation (n=255, 62.0%), medical thromboprophylaxis (n=52, 12.7%) and venous thromboembolism (n=53, 12.9%). Direct oral anticoagulants (DOAC) were most frequently prescribed (n=309, 75.2%). Of 411 prescription reviews, 93 led to at least one intervention (22.6%), for a total of 100 interventions. Interventions mainly concerned laboratory ordering (n=29) and DOAC dose adjustment (n=24). Baseline anticoagulant characteristics and outcomes varied by healthcare setting. Expanding ACSP into outpatient LTC and RC settings is feasible. ACSP should include both therapeutic and thromboprophylactic anticoagulants. Additional research is warranted to evaluate the viability of ongoing ACSP monitoring, and more extensive prospective studies are required to assess clinical outcomes effectively.

Electrochemical skin conductance to assess peripheral neuropathy in rheumatic diseases with or without type 2 diabetes using sudoscan

ABSTRACT Introduction: Peripheral neuropathy (PN) occurs in diabetes mellitus. However, the association between PN and rheumatic disease (RD) has not been fully investigated. The aim of this study was to assess the prevalence of PN in patients with RDs with or without Diabetes Mellitus. Methods: A Cross-sectional cohort study, data extracted from patients medical records started in September 2023 to January 2024 in Abu Dhabi, UAE. A Sudoscan machine report was used to assess The electrochemical skin conductance (ESC), Sudomotor dysfunction is evaluated according to the ESC measured on the feet: >60 μS = no dysfunction; 60–40 μS = moderate dysfunction; and <40 μS = severe dysfunction. Results: Eighty-one patients with RDs, mean age 58 ± 12. There were 55 females (67.9%), and 26 males (32.1%) attended an ambulatory healthcare clinic in Abu Dhabi, UAE. Thirty-three (40.7%) had diabetes, while 48 (59.3%) did not have diabetes. The mean glycated haemoglobin A1c (HBA1c) was 7.4% in diabetic patients and 5.8% in non-diabetic patients Additionally, all patients had a mean blood pressure of 134/72 and a mean Body Mass Index (BMI) of 31.40 kg/m2. Among the study patients, the most common RD was osteoarthritis, which affected 56.8% of the patients. The smallest percentage of patients with PN was found in those with IgG4, at 1.2%. The prevalence of Sudomotor dysfunction (ESC feet: <60 μS) was 72.8% in patients with RDs (all patients diabetic and non-diabetic), while the prevalence of sudomotor dysfunction (ESC feet: <60 μS) in RDs patients with diabetes was 75.8% and 70.8% in RDs patients without diabetes, there was no significant difference between in prevalence of sudomotor dysfunction in RD patients with diabetes compared to RD patients without Diabetes. Conclusion: Sudomotor dysfunction appears to be common among patients with RD regardless they have diabetes or not. This study recommends screening all RD patients for Sudomotor Dysfunction.

Is the US infusion capacity sufficient for the expected demand with the emergence of disease‐modifying Alzheimer’s treatments?

AbstractBackgroundDisease‐modifying treatments for Alzheimer’s disease (AD) are becoming available. To date, all current treatments require intravenous infusion, and concerns have emerged that lack of infusion capacity may limit access to treatment. We predict supply and demand for infusions for AD treatment in the US under different assumptions over a 10‐year period.MethodWe use a Markov model to predict the number of individuals identified as eligible for AD treatment from 2023 to 2032, taking into account constrained capacity for AD specialist visits and confirmatory biomarker testing. We analyze chronic treatment starting at mild cognitive impairment (70% of patients) and mild dementia (30%) until transition to moderate dementia with infusions every two and four weeks for an estimated duration of 5.7 years, and time‐limited treatment every four weeks for 52 weeks as a lower bound estimate. National historic trends of infusion capacity were obtained from the CDC’s Ambulatory Health Care Data surveys and projected forward. Estimates for excess capacity and future growth of capacity for AD treatment were obtained from a survey covering 404 US infusion centers.ResultThe model predicts that 370,527 patients would be eligible to start treatment in 2023, increasing by 1% per year. Based on the CDC data, around 21 million infusions across therapeutic areas would be provided in 2023 with a projected annual growth rate of 3%. The survey of infusion centers suggests that 3% of capacity is currently devoted to AD with that share growing 1% per year, as well as up to 17% average unused capacity. Figure 1 shows the projected supply and demand. The solid lines show demand for the three types of treatment, the green and black dashed lines the projected supply and the maximum projected supply, if all unused capacity were devoted to AD infusions.ConclusionProjected US infusion capacity would be insufficient for all three treatment types, and even the maximum projected capacity would only be sufficient for time‐limited treatments. Expansion of capacity and introduction of treatments that do not require intravenous infusions will be necessary to ensure timely access to treatment.

Social determinants of health and mild cognitive impairment in a diverse community sample.

The associations between community-wide social determinants of health and mild cognitive impairment (MCI) among individuals warrant investigation. Among 2830 dementia-free individuals aged 65+ years in a community-based US study, we examined cross-sectional associations of MCI (Clinical Dementia Rating = 0.5) with the following potential social determinants of health: at the census tract or block group level obtained from public sources: neighborhood disadvantage (Area Deprivation Index, ADI), air pollution with fine particulate matter (PM2.5), greenspace, Walkability Index, ambulatory healthcare availability per square mile, homicide rate; and at the individual participant level, birth/schooling in a southern US state. Unadjusted logistic regression models found higher odds ratios (OR, 95% CI) for MCI with higher ADI (1.01, 1.003-1.02), higher PM2.5 (1.16, 1.07-1.26), higher homicide rate (1.007, 1.001-1.012), lesser greenspace (0.99, 0.90-0.99), and southern schooling (2.06, 1.6-3.54). Adjusting for age, race, sex, and educational level, ADI remained statistically significant (1.04, 1.01-1.06), while PM2.5 and Southern state schooling interacted significantly with race and were more strongly affected in Black participants than in White participants. In this cohort, several community-wide social/environmental factors were associated with MCI. While clinicians should continue to encourage older adults to modify their individual risk factors, policy changes are needed to mitigate social determinants of health in the community.

Implementing laboratory internal audit to improve compliance and quality of care in the municipal public health system-based ambulatory care health clinics in New York city.

System-wide laboratory internal audits are useful to help laboratories prepare for external audits in addition to being part of the ongoing program for compliance improvement and quality assurance in the laboratory to track and enhance care quality. A formal plan was developed and a modified audit checklist was prepared by our laboratory management team, applicable and uniquely tailored for our ambulatory care clinic settings to track operational, quality, and compliance metrics according to the New York State Department of Health Clinical Laboratory Evaluation Program. Two audits were conducted 6 months apart and the conformity documented. An overall 84% increase in compliance and conformity was observed between first and second audits, which ranged from 63% to 100% across different categories, with 100% improvement (0% nonconformity) in 75% of the sites in the second audit. A system-wide laboratory internal audit was created and carried out. Staff shortages, rapid turnover, and lack of retraining were found to be contributing factors to sites that did not achieve 100% conformance. Continuous assessment and monitoring are key elements to success in the laboratory quality management system, and through this scheduled audit process, we were able to achieve continual laboratory quality improvement.

Addressing Lean and Safety Readiness Assessment in Territorial Ambulatory Healthcare

Within the international healthcare landscape, it is incumbent upon all organisations to proactively address individual patient needs by offering a wide range of services. In this context, Territorial Ambulatory Healthcare (TAH) is critical to promote equal access to care as the primary point of contact between National Healthcare Systems and individuals. To achieve this goal, the adoption of Lean and Safety Management (L&SM), a managerial approach to proactively reduce clinical risk and process inefficiencies, can support organisations in pursuing high quality care objectives. Despite the positive benefits associated with the adoption of this approach, the feasibility of guaranteeing a sustainable care quality over time may encounter several challenges. Among these, key contributors to failure include the lack of tailored tools and practices suitable for the healthcare environment, insufficient readiness of the context for implementation, and the absence of a comprehensive system-wide performance strategy. Recent studies in literature address these issues presenting theoretical and practical models to assess readiness levels, highlighting opportunities for future developments of these topics. The current empirical study contributes to the existing knowledge by creating a framework to assess the level of readiness for L&SM implementations within TAH. While this context is essential for ensuring high-quality care and equitable access to care services, successfully implementing L&SM initiatives within TAH is challenging due to the organizational complexity and the involvement of multiple, fragmented stakeholders and care providers. Addressing weak Critical Readiness Factors (CRFs) before starting a project can significantly contribute to successfully implement L&SM and sustain improvement over time. This study will be conducted within the TAH setting of a healthcare organisation in Northern Italy and aims 1) to evaluate the specific care setting readiness for L&SM implementations and 2) to develop practical guidelines to support the organisation in increasing its actual readiness level. The theoretical framework will be grasped integrating prior research on Lean readiness assessment, along with specific literature on L&SM sustainability implementation factors within TAH. Once refined and tested with the purpose of developing a practical assessment tool, the framework will be applied within the selected setting, leading to the identification of practical guidelines to facilitate project success and improvements sustainability. Overall, this research will contribute to enrich the knowledge about L&SM implementation within TAH, supporting health organisations, managers, and clinical leadership to sustainably improve care quality, enhancing the role of territorial care to foster social well-being.

Direct annual healthcare costs in survivors of acute pulmonary embolism: estimates based on a prospective multicentre cohort study

Abstract Background Patients surviving acute pulmonary embolism (PE) necessitate long-term care and follow-up. However, the economic impact of PE on healthcare systems after the acute event remains largely unknown. Purpose To estimate the direct cost of PE during the first year after discharge from hospital for the index event, focusing on rehospitalizations, anticoagulant medication, and outpatient follow-up. Methods We analyzed the data from a multicentre cohort study of 1017 unselected patients with confirmed acute symptomatic PE in Germany. After the index episode, the costs of which were not considered, patients prospectively followed an outpatient visit plan at 3, 12 and 24 months. All rehospitalisations were documented with the main and accompanying diagnoses; hospital costs were calculated based on current reimbursement in the German Diagnosis Research Groups (G-DRG) system. The duration and type (central unique drug identifier) of anticoagulant treatment was documented at each visit. Per-patient costs of ambulatory follow-up visits and tests were calculated by multiplying (i) the costs of each visit/test (German ambulatory healthcare services reimbursement catalogue) by (ii) the probability π (0.0≤π≤1.0) of needing that specific service, based on the PE follow-up algorithm of the ESC Guidelines which we populated with the actual results per step in the present study (Figure). The primary analysis was conducted in all patients with ≥3-month follow-up. An additional sensitivity analysis included only the patients completing ≥12-month follow-up. We additionally identified the baseline predictors for the number of rehospitalizations and costs using multivariable zero-inflated Poisson and hurdle regression and accounting for censored data. Results Of 1017 enrolled patients, 958 (94%) were included in the primary analysis. Of them, 24% were rehospitalized, for a marginal mean of 0.34 (bootstrapped 95% CI: 0.30-0.39) readmissions per PE survivor. Age, coronary artery, pulmonary and kidney disease, diabetes, and (in the sensitivity analysis) cancer, emerged as independent cost predictors by multivariable hurdle gamma regression (Table). Estimated overall rehospitalisation costs were €1138 (95% CI 896-1420) per patient (€1171 [908-1479] in the sensitivity analysis). Mean anticoagulation duration was 330 days, with estimated per-patient costs of €1050 (€1190 in the sensitivity analysis). Per-patient costs of ambulatory follow-up visits and tests were estimated at €182, yielding a total cost of illness per PE survivor of €2370-2543. For the entire country, the annual direct costs after acute PE would thus amount to €202-217 million. Conclusions By estimating per-patient costs and identifying major cost drivers of post-PE care, the present study may inform decisions concerning implementation and reimbursement of follow-up programmes aiming at improved overall cardiovascular prevention.TableFigure

Paintable, Fast Gelation, Highly Adhesive Hydrogels for High-fidelity Electrophysiological Monitoring Wirelessly.

High-fidelity wireless electrophysiological monitoring is essential for ambulatory healthcare applications. Soft solid-like hydrogels have received significant attention as epidermal electrodes because of their tissue-like mechanical properties and high biocompatibility. However, it is challenging to develop a hydrogel electrode that provides robust contact and high adhesiveness with glabrous skin and hairy scalp for high-fidelity, continuous electrophysiological signal detection. Here, a paintable, fast gelation, highly adhesive, and conductive hydrogel is engineered for high-fidelity wireless electrophysiological monitoring. The hydrogel, consisting of gelatin, gallic acid, sodium citrate, lithium chloride, glycerol, and Tris-HCl buffer solution exhibits a reversible thermal phase transition capability, which endows it with the attributes of on-skin applicability and fast in situ gelation with 15 s, thereby addressing the aforementioned limitations. The introduction of gallic acid enhances the adhesive properties of the hydrogel, facilitating secure electrode attachment to the skin or hairy scalp. To accentuate the potential applications in at-home electrophysiological health monitoring, the hydrogel electrodes are demonstrated for high-fidelity electrocardiogram recording for one hour during various daily activities, as well as in simultaneous electroencephalogram and electrocardiogram recording during a 30 min nap.

Referral, monitoring, and factors associated with non-referral of chronic kidney disease in Germany: a nationwide, retrospective cohort study

Chronic kidney disease (CKD) is one of the most significant drivers of the global burden of disease and an increasing public health issue. Adequate monitoring and referral of high-risk patients to nephrologists are associated with improved management of CKD. We aimed to assess nephrology referral rates, monitoring of kidney function, and factors associated with failure to refer in Germany. We retrospectively analyzed ambulatory claims data of 73,675,956 German patients who were covered by statutory health care in 2022, building a cohort of 1,301,122 patients who had at least two diagnoses of CKD stage 3-5 within the calendar year. In our analysis, we focused particularly on patients with CKD stage4. We identified 207,043 patients with CKD stage 4, of which 134,143/207,043 (64.8%) received nephrologist treatment in 2022. The median age of the cohort was 82 years. Failure to quantify proteinuria occurred in 61,991/72,900 (85.0%) non-referred patients compared to 51,382/134,143 (38.3%) referred patients. In a mixed logistic regression model, referral was less likely for women (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.71-0.74), higher age (OR per year 0.97, CI 0.96-0.97), nursing home inhabitants (OR 0.63, CI 0.61-0.65), and those with certain comorbidities. Regional factors (deprivation, population density, nephrologist density) were not associated with referral. A substantial proportion of patients with late-stage CKD are not receiving guideline-recommended kidney care in the German health care system, with disparities driven primarily by individual patient factors rather than geographical barriers. This study was funded by the University Hospital Schleswig-Holstein and the Central Research Institute of Ambulatory Health Care in Germany.

Frailty assessment and outcomes in primary care for patients with diabetes during Ramadan: implications for risk evaluation and care plans.

Frailty is a critical concern for older adults, impacting their susceptibility to adverse events and overall quality of life. This study aimed to determine the frailty status of patients 60 years or older in Abu Dhabi Ambulatory Healthcare Services (AHS) and assess its relation to the stress exerted by Ramadan fasting and the occurrence of any adverse outcomes. In this prospective observational study, participants were included if the attending physicians used the IDF-DAR risk stratification assessment tool. A tele-interview was conducted to complete the FRAIL score within 6 weeks before Ramadan 1,444 (CE 2022). The outcome was assessed through another tele-interview and an electronic medical record review after Ramadan. According to the FRAIL assessment tool, among the 204 patients aged 60 years or older included in the study, 109 (53.4%) were classified as either frail or pre-frail. In total, 20 (9.8%) patients were frail, that is, 1 out of 10, and 89 (43.6%) were pre-frail. The remaining 95 (46.6%) patients were robust. Using logistic regression to assess the occurrence of adverse outcomes after Ramadan fasting, a higher frailty score was identified as the third independent risk factor [B = 0.4, OR = 1.5 (1-2.02-1.86), and p = 0.039] for experiencing an adverse event. The identified factors associated with frailty were age, increased albumin-to-creatinine ratio (ACR), chronic kidney diseases (CKDs), and ischemic heart diseases (beta = 0.27, p = 0.003; beta = 0.24, p = 0.004; beta = 0.2, p = 0.039; and beta = 0.18, p = 0.041, respectively). One-third of the frail patients had an event, while the incidence in pre-frail patients was 11.2%, and among the robust patients, the incidence was 6.3%. Physicians' global assessment of frailty did not align well with the structured FRAIL scoring. Only five (25%) out of the 20 patients identified as frail by the FRAIL assessment tool were also judged as frail or having cognitive function impairment by the physicians' global assessment tool. Frailty is prevalent among elderly patients with diabetes. Disparity exists between subjective and objective frailty assessments, emphasizing the need for standardized evaluation methods. Using the FRAIL tool is recommended for patients aged 60 or older with diabetes in Abu Dhabi.

Identifying points of interest (POIs) as sentinels for infectious disease surveillance: A COVID-19 study

Traditional surveillance relies on medical facilities, such as clinics and laboratories, as sentinels to monitor disease activities. Few studies have investigated the feasibility of using Point of Interests (POIs) as sentinels for disease surveillance. POIs, such as restaurants, retail stores, and churches, are places where people often interact with one another and thus play a critical role in transmission of infectious diseases like influenza and COVID-19. To fill this gap, we proposed a method to estimate people's potential crowdedness at POIs and explored its utility as an early indicator to signal local disease outbreaks. In a case study in Florida, USA, we utilized weekly foot traffic data at 0.3 million POIs to calculate their weekly crowdedness, and tested local correlations between the crowdedness of each POI and its surrounding COVID-19 incidences with different time lags. We identified 261 POIs as potential sentinels that could signal the risk one to three weeks ahead of disease outbreaks. Most of these sentinel POIs provided food/drink services, ambulatory healthcare and religious/civic services. They were characterized by a relatively large group of customers and a stable patronization over time. This research provides new insights into improving current disease surveillance systems by incorporating more diverse and widely distributed POIs.

Wastewater and clinical surveillance of respiratory viral pathogens on a university campus

Areas of dense population congregation are prone to experience respiratory virus outbreaks. We monitored wastewater and clinic patients for the presence of respiratory viruses on a large, public university campus. Campus sewer systems were monitored in 16 locations for the presence of viruses using next generation sequencing over 22 weeks in 2023. During this period, we detected a surge in human adenovirus (HAdV) levels in wastewater. Hence, we initiated clinical surveillance at an on-campus clinic from patients presenting with acute respiratory infection. From whole genome sequencing of 123 throat and/or nasal swabs collected, we identified an outbreak of HAdV, specifically of HAdV-E4 and HAdV-B7 genotypes overlapping in time. The temporal dynamics and proportions of HAdV genotypes found in wastewater were corroborated in clinical infections. We tracked specific single nucleotide polymorphisms (SNPs) found in clinical virus sequences and showed that they arose in wastewater signals concordant with the time of clinical presentation, linking community transmission of HAdV to the outbreak. This study demonstrates how wastewater-based epidemiology can be integrated with surveillance at ambulatory healthcare settings to monitor areas prone to respiratory virus outbreaks and provide public health guidance.

Finding Our Lanes: A Roadmap for Collaboration Between Academic Medical Centers and Behavioral Telehealth Companies.

Outpatient mental health care in the United States is delivered by an uncoordinated patchwork of public and private entities that struggle to effectively differentiate the care they provide. The COVID-19 pandemic catalyzed transformative changes in this space, including rapid adoption of telehealth and escalating private sector investment to provide services for individuals wishing to obtain care through insurance. In this article, we briefly review the current landscape of ambulatory mental health care. Utilizing Kissick's Iron Triangle model of health care delivery, we compare the relative strengths and weaknesses of academic medical centers and the growing private sector, entities potentially positioned to synergistically foster a mental health ecosystem with improved quality, access, and cost-effectiveness. A roadmap for strategic integration is presented for how academic centers-institutions frequently overwhelmed by patient volume-might leverage partnerships with a private sector eager to utilize novel technology to improve access, demonstrate data-driven outcomes, and advocate for improved reimbursement from payers. We also assess the potential risks and pitfalls of such collaboration. In return, academic institutions can refocus on their strengths, including research, systems knowledge, quality-improvement initiatives, education and training, and specialty clinical care.

Racial-Ethnic Disparities in Quality of Care Among Medicaid Beneficiaries With Schizophrenia.

The authors sought to update and expand the evidence on the quality of health care and disparities in care among Medicaid beneficiaries with schizophrenia. Adult beneficiaries of New York State Medicaid with schizophrenia receiving care during 2016-2019 were identified. Composite quality scores were derived from item response theory models by using evidence-based indicators of the quality of mental and general medical health care. Risk-adjusted racial-ethnic differences in quality were estimated and summarized as percentiles relative to White beneficiaries' mean quality scores. The study included 71,013 beneficiaries; 42.8% were Black, 22.9% Latinx, 27.4% White, and 6.9% other race-ethnicity. Overall, 68.8% had a mental health follow-up within 30 days of discharge, and 90.2% had no preventable hospitalizations for chronic obstructive pulmonary disease or asthma. Among beneficiaries receiving antipsychotic medications, medication adherence was adequate for 43.7%. Fourteen indicators for mental and general medical health care quality yielded three composites: two for mental health care (pharmacological and ambulatory) and one for acute mental and general medical health care. Mean quality of pharmacological mental health care for Black and Latinx beneficiaries was lower than for White beneficiaries (39th and 44th percentile, respectively). For Black beneficiaries, mean quality of ambulatory mental health care was also lower (46th percentile). In New York City, Black beneficiaries received lower-quality care in all domains. The only meaningful group difference in the quality of acute mental and general medical health care indicated higher-quality care for individuals with other race-ethnicity. Disparities in the quality of Medicaid-financed health care persist, particularly for Black beneficiaries. Regional differences merit further attention.

Too many cooks could spoil the broth: choice overload and the provision of ambulatory health care

Patient empowerment calls for an intensified participation of (informed) patients with more treatment opportunities to choose from. A growing body of literature argues that confronting consumers with too many opportunities can lead to a choice overload (CO) resulting in uncertainty that the selected alternative dominates all other options in the choice set. We examine whether there is a CO effect in the demand for ambulatory health care in Germany by analyzing the association of medical specialists supply on so-called patients’ health uncertainty. Further, we investigate if the CO effect is smaller in areas with a higher density of general practitioners (GPs). We find that patients who live in an area with a large supply of specialists are subject to a CO effect that is expressed by an increased health uncertainty. The coordinating role of GPs seems to be effective to reduce the CO effect, while preserving free consumer choice.

Successful hepatitis B and C screening in the health check-up in the German primary care setting

Successful hepatitis B and C screening in the health check-up in the German primary care setting

Evaluation of medications used for opioid use disorder in emergency departments: A cross-sectional analysis of the 2020 National Hospital Ambulatory Medical Care Survey

IntroductionOpioid use disorder (OUD) is a significant health issue impacting millions in the United States (US). Medications used for OUD (MOUD) (e.g., buprenorphine, methadone, naltrexone) and medications for overdose and symptom management (e.g., naloxone, clonidine) have been shown to be safe and effective tools in clinical management. MOUD therapy in Emergency Departments (EDs) improves patient outcomes and enhances engagement with formal addiction treatment; however, provider factors and institutional barriers have created hurdles to ED-based MOUD treatment and heterogeneity in ED based OUD care. We used a nationally representative dataset, the National Hospital Ambulatory Medical Care Survey (NHAMCS) to characterize MOUD prescribing practices across patient demographics, geographic regions, payers, providers, and comorbidities in EDs. MethodsNHAMCS is a survey conducted by the US Census Bureau assessing utilization of ambulatory healthcare services nationally. Survey staff compile encounter records from a nationally representative sample of EDs. We conducted a cross-sectional study using this data to assess visits in 2020 among patients aged 18–64 presenting with an opioid overdose or OUD. We estimated the proportion of patients who had any MOUD, clonidine, or naloxone treatment and 95% confidence intervals (CI). We modeled the association between patient demographic, location, comorbidities, and provider characteristics with receipt of MOUD treatment as unadjusted odds ratios (OR) and 95% CI. ResultsThere was a weighted frequency of 469,434 patients who were discharged from EDs after being seen for OUD or overdose. Naloxone, clonidine, and buprenorphine were the most frequent treatments administered and/or prescribed for OUDs or overdose. Overall, 54,123 (11.5%, 95%CI 0–128,977) patients who were discharged from the ED for OUDs or overdose received at least one type of MOUD. Hispanic race, (OR 17.9, 95%CI 1.33–241.90) and Western region (OR43.77, 95%CI 2.97–645.27) were associated with increased odds of receiving MOUDs, while arrival by ambulance was associated with decreased odds of receiving MOUDs (OR0.01, 95%CI 0.001–0.19). Being seen by an APP or physician assistant was associated with MOUD treatment (OR 16.68, 95%CI: 1.41–152.33; OR: 13.84, 95%CI: 3.58–53.51, respectively). ConclusionOur study findings suggest that MOUD and other medications for opioid overdose are infrequently used in the ED setting. This finding was especially notable in race, geographic region, mode of arrival, and those seen by APP, underscoring the need for further study into the root causes of these disparities. Our study provides a foundational understanding of MOUD patterns, guiding future research as the landscape of OUD treatment continues to shift.

Interventions in ambulatory healthcare settings to reduce social isolation among adults aged 18-64: a systematic review.

Social isolation is associated with increased all-cause and premature mortality, poor chronic disease management, and mental health concerns. Limited research exists on interventions addressing social isolation among individuals under 65 despite its increasing prevalence among young and middle-aged adults. To identify interventions from the extant literature that address social isolation and loneliness in ambulatory healthcare settings in adults aged 18-64 and to identify elements of successful studies for future intervention design. Systematic review of interventions targeting social isolation in community-dwelling adults aged 18-64 within ambulatory healthcare settings. A search strategy was developed to identify relevant articles in the following databases: Ovid MEDLINE, Embase, EBM Reviews, Scopus, CINAHL, and PsychInfo. Data were extracted on study design and setting, intervention type, outcome related to social isolation/loneliness, and scale of measure used. 25 078 citations were identified and underwent title and abstract screening. 75 articles met our inclusion criteria and were synthesised, including an assessment of bias. Effective interventions were delivered in community health settings, incorporated a group component, and used digital technologies. They also addressed the association between mental health and social isolation using cognitive-behavioural therapy (CBT) approaches and enhanced self-management and coping strategies for chronic conditions through psycho-educational interventions. Future research should prioritise adults living in low-income and middle-income countries, racialised individuals, as well as those with fewer educational opportunities. There is also a need to advance research in primary care settings, where longitudinal patient-provider relationships would facilitate the success of interventions.

Coronary CTA in statutory, ambulatory health care

Coronary CTA in statutory, ambulatory health care

Surgeon Perceptions of Performing Transforaminal Lumbar Interbody Fusion in an Ambulatory Surgical Center vs Hospital Setting in the Elderly Population: Results of a Surgeon Survey.

There is an increasing acceptance of conducting minimally invasive transforaminal lumbar interbody fusion (TLIF) in ambulatory surgical centers (ASCs). The Centers for Medicare and Medicaid Services (CMS) introduced the Hospitals Without Walls (HWW) program in March 2020. This program granted hospitals regulatory flexibility to offer services and procedures in nontraditional locations, including ASCs. However, implementation hurdles persist. A survey was sent to 235 surgeons regarding the use of ASCs for performing TLIF surgeries on elderly patients. Multiple-choice questions covering various aspects of TLIF practice preferences, including surgical indications, decision factors for choosing ASCs over hospitals, implementation hurdles, reimbursement concerns, staffing issues, and the impact of CMS rules and regulations on TLIF in ASCs, particularly concerning physician ownership and self-referral conflicts governed by the Stark law, were asked. The survey completion rate was 25.8% (Figure 1). The most common surgical indications for TLIF in ASCs were spondylolisthesis (80%), spinal stenosis (62.5%), and low back pain (47.5%). Most surgeons (78%) believed TLIF could be safely performed in ASCs. Streamlined workflow, lower infection rates, and cost-effectiveness were advantages listed by 58.5% of surgeons. Patient's medical history (75.8%), followed by ASC resources and capabilities (61%) and surgeon preference (61%), were relevant factors. Higher efficiencies at ASCs (14.6%), contractual issues (9.8%), and ownership issues (7.3%) were less relevant to surgeons. About 65.9% of surgeons reported lower reimbursement in ASCs, and 43.9% said it was an implementation hurdle. Lower direct costs were reported by 53.7% of surgeons. Other hurdles included a lack of trained staff (24.4%), inadequate staffing (22.0%), cost overruns (26.8%), high Joint Commission or the Accreditation Association for Ambulatory Health Care credentialing costs, and surgeons feeling uncomfortable performing TLIF in ASCs (22.0%). Only 17.1% listed medical problems as a reason their patient was considered unsuitable for the ASC environment. A majority (53.7%) stated that their ASCs complied with strict Stark requirements by disclosing physician ownership interests. However, 22% of surgeons reported self-referrals under the "In-Office Ancillary Services Exception" allowed by the Stark law. Our survey data show that surgeons' perceptions of current CMS rules and regulations may hinder the transition into the ASC setting because they think the reimbursement is too low and the regulatory burden is too high. ASCs have disproportionally higher initial acquisition and ongoing costs related to staff training and maintenance of the TLIF technology that CMS should consider when determining the appropriate financial remuneration for these complex procedures. ASC offers a viable and attractive option for their TLIF procedure with the advantage of same-day discharge and at-home recovery.