Ambulatory Medical Visits Research Articles

Factors Associated with Long COVID-19 in a French Multicentric Prospective Cohort Study.

(1) Background: A substantial proportion of COVID-19 patients continue to experience long-lasting effects that hamper their quality of life. The objectives of this study were (1) to report the prevalence of persistent clinical symptoms 6-12 months after the onset of COVID-19 and (2) to identify potential factors at admission associated with the occurrence of long COVID. (2) Methods: A prospective study was conducted among COVID-19 adult patients, hospitalized in four French university hospitals. Patients were invited to two ambulatory follow-up medical visits, 6-8 months (visit #1) and one year (visit #2) after the onset of their COVID-19. A multivariate logistic regression was performed to assess factors associated with long COVID. (3) Results: In total, 189 patients participated in this study (mean age of 63.4 years). BMI > 30 kg/m2 (aOR 3.52), AST levels between 31 and 42 U/L (aOR 8.68), and AST levels > 42 U/L (aOR 3.69) were associated with persistent clinical symptoms at visit #1. Anosmia (aOR 13.34), AST levels between 31 and 42 U/L (aOR 10.27), stay in ICU (aOR 5.43), pain (aOR 4.31), and longer time before hospitalization (aOR 1.14) were significantly associated with persistent clinical symptoms at visit #2. Patients with ageusia (aOR 0.17) had a lower risk of long COVID. (4) Conclusions: This study showed that some patients experienced persistent clinical symptoms one year after COVID-19 onset that were associated with some determinants at the acute phase/stage.

Abstract 9771: Trends in Blood Pressure Treatment Intensification in Older Adults With Hypertension in the United States, 2008-2018

Introduction: Hypertension control has worsened in recent years, yet trends for appropriate blood pressure intensification practices for older adults is unknown. Hypothesis: We determine the proportion of ambulatory visits where older adults with hypertension were appropriately intensified on anti-hypertensives over the past decade. We hypothesize that treatment intensification may not have improved over time. Methods: Data from National Ambulatory Medical Care Survey (NAMCS, 2008-2018) were used. NAMCS is a nationally representative sample of ambulatory medical visits. Adults ages 60 years or older were included. Appropriate antihypertensive intensification was defined as the addition of an antihypertensive for a blood pressure reading above target. We examined appropriate intensification by blood pressure targets set by the ACC/AHA, the ESC, and the ACP/AAFP guidelines for older adults. Further, we defined an additional all-inclusive criterion meeting all three guidelines. Results: From 2008-2018, appropriate treatment intensification by ACC/AHA guidelines occurred at 11.1% (95% CI:9.8-12.5%) of visits, decreasing from 13.6% (95% CI:15.6-28.7%) of visits in 2008-2009 to 10.4% (95% CI:10.9-26.4%) in 2015-2018. Appropriate intensification by ESC occurred at 14.2% (12.1-16.6%) of visits over 2008-2018, decreasing from 16.9% (95% CI:13.5-21.0%) in 2008-2009 to 12.5% (95% CI:7.4-20.3%) from 2015-2018. Appropriate intensification by AAFP/ACP occurred at 18.9% (16.2-22.0%) of visits over 2008-2018, decreasing from 24.7% (95% CI:20.2-29.0%) in 2008-2009 to 14.9% (95% CI:9.0-23.7%) from 2015-2018. By all-inclusive criteria, intensification trended towards worsening with time: odds ratio: 0.93 (95% CI:0.87-1.00; p=0.07). Conclusions: Appropriate treatment intensification for older adults with hypertension in the US was suboptimal over the past decade despite growing trial evidence showing beneficial effects for intensive blood-pressure control in older adults. Strategies to mitigate therapeutic inertia are needed, and clinical practices should make concerted efforts to improve appropriate treatment intensification in older adults.

878. Telemedicine Implementation in a Midwestern HIV Clinic: One Year Outcomes

BackgroundDuring the COVID-19 pandemic, we realized the importance of limiting in-clinic interactions with patients who were stable on antiretroviral therapy to promote social distancing. Our HIV clinic adopted telemedicine practices, in line with the HHS Interim Guidance for COVID-19 and Persons With HIV. Several HIV clinics reported lower viral suppression rates during the pandemic. We aim to describe the implementation process as well as year one outcomes of telemedicine at our clinic.MethodsIn March 2020, we created telemedicine protocols; we also designed and continuously updated algorithms for determining patient eligibility for telemedicine based on recent viral loads and last clinic visit. We monitored outcomes through electronic medical record chart reviews between May 1, 2020, and April 30, 2021. We collected patient demographics, and federal poverty level (FPL) information. We collected baseline and post-intervention rates of viral load suppression (VLS, defined as HIV RNA < 200 copies per mL), medical visit frequency (MVF, defined as percentage of patients who had one visit in each 6 months of the preceding 24 months with at least 60 days between visits) and lost to care (LOC, no follow up within 12 months period).ResultsWe conducted a total of 2298 ambulatory medical visits; 1642 were in person and 656 (29%) were telemedicine visits. Out of those, 2177 were follow up visits (649, 30% telemedicine). There was no difference of telemedicine utilization based on race (28% in African Americans vs. 32% in Whites); ethnicity (30% in Hispanic vs. 30% in Hon-Hispanic); gender (24% in females vs. 30% in males); or FPL (28% in FPL < 200% vs. 31% in FPL >200%). By the end of April 2021, overall clinic VLS rate was 94%, MVF was 48%, and there were 40 patients LOC compared to 92%, 49%, and 43 patients in April 2020, respectively.ConclusionTelemedicine was a safe alternative to routine in-person HIV care during the COVID-19 pandemic. We observed similar rates of utilization across demographic and FPL status. Applying selection criteria, viral suppression and retention in care rates were not adversely impacted by shift to telemedicine modality. Disclosures All Authors: No reported disclosures

Medical Care at California Wildfire Incident Base Camps.

The California Emergency Medical Services Authority manages and deploys California Medical Assistance Teams (CAL-MAT) to disaster medical incidents in the state. This analysis reviews diagnoses for ambulatory medical visits at multiple wildland fire incident base camp field sites in California during the 2020 fire season. Clinical data without personal health information were extracted retrospectively from patient care records from all patients seen by a provider. Results were entered into Excel spreadsheets with calculation of summary statistics. During the 2020 fire season, CAL-MAT teams deployed 21 times for a total of 327 days to base camps supporting large fire incidents and cared for 1756 patients. Impacts of heat and environmental smoke are a constant factor near wildfires; however, our most common medical problem was rhus dermatitis (54.5%) due to poison oak. All 2020 medical missions were further complicated by prevention and management of coronavirus disease (COVID-19). There is very little literature regarding the acute medical needs facing responders fighting wildland fires. Ninety-five percent of clinical conditions presenting to a field medical team at the wildfire incident base camp during a severe fire season in California can be managed by small teams operating in field tents.

PRS31 Evaluation of Health Care Resource Utilization (HCRU) within Baseline Exacerbation Subgroups Among Patients with COPD Initiating Combination Tiotropium/Olodaterol (TIO+OLO) Versus Triple Therapy (TT)

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) affected 251 million people and caused 5% of deaths worldwide in 2016. GOLD recommends long-acting muscarinic antagonists/beta2-agonists (LAMA+LABA) as next-in-line therapy for symptomatic COPD patients on mono-maintenance therapy; ultimately escalating to TT (LAMA+LABA+inhaled corticosteroids) upon further exacerbations and post-risk/benefit (e.g., pneumonia) assessment. Compare COPD-related, non-COPD pneumonia-related, and all-cause HCRU among TIO+OLO (a fixed-dose LAMA+LABA inhaler) vs. TT initiators, in a U.S. Medicare Advantage population with COPD stratified by baseline exacerbation history (surrogate measure for disease severity): none=0 (subgroup N=737); single=1 moderate (N=275); multiple/severe=≥2 moderate or ≥1 severe exacerbation[s] (N=228). This retrospective observational post-hoc analysis involved COPD patients ≥40 initiating TIO+OLO or TT between 01Jan2014-31Mar2018. 12 months pre-index and ≥30 days post-index continuous medical/pharmacy coverage was required. Patients were propensity score matched 1:1. Annualized population averages were estimated. Among patients with no exacerbation history, TIO+OLO had significantly lower COPD-related mean inpatient (0.20 vs. 0.49) and length of stay (1.18 vs. 3.46 days), ambulatory (5.01 vs. 6.78; all p<0.001) and emergency room (ER; 0.24 vs. 0.42; p<0.05) visits. Non-COPD pneumonia-related mean inpatient (0.05 vs. 0.15; p=0.007) and ER (0.04 vs. 0.09; p=0.036) visits were lower. All-cause HCRU was significantly lower across all settings. Among single, multiple/severe subgroups, TIO+OLO had lower COPD-related ambulatory (6.90 vs. 9.92; 8.96 vs. 13.22 respectively; all p≤0.003) and other medical (3.35 vs. 5.88; 6.87 vs. 10.01 respectively; all p<0.015) visits. From a HCRU perspective, these real-world findings question the value of prescribing TT across all COPD severities.

Varicella healthcare resource utilization in middle income countries: a pooled analysis of the multi-country MARVEL study in Latin America & Europe

ABSTRACT Varicella is a mild and self-limited illness in children, but can result in significant healthcare resource utilization (HCRU). To quantify/contrast varicella-associated HCRU in five middle-income countries (Hungary, Poland, Argentina, Mexico, and Peru) where universal varicella vaccination was unimplemented, charts were retrospectively reviewed among 1–14 year-olds. Data were obtained on management of primary varicella between 2009–2016, including outpatient/inpatient visits, allied healthcare contacts, tests/procedures, and medications. These results are contrasted across countries, and a regression model is fit to extrapolated country-level costs as a function of gross domestic product (GDP). A total of 401 outpatients and 386 inpatients were included. Significant differences between countries were observed in the number of skin lesions among outpatients, ranging from 5.3% to 25.4% of patients with ≥250 lesions. Among inpatients, results were less variable. Average ambulatory medical visits ranged from 1.1 to 2.2. Average hospital stay ranged from 3.6 to 6.8 days. Use of tests/procedures was infrequent in outpatients, except in Argentina (13.3%); among inpatients, a test/procedure was ordered for 81.3% of patients, without regional variation. Prescription medications were administered in 44.4% of outpatients (range 9.3%–80.0%), and in 86% of inpatients (range 70.4%–94.9%). Total estimated spending on varicella treatment in the absence of vaccination was predicted from income levels (GDP) with an exponential function (R2 = 0.89). This study demonstrates that substantial HCRU is associated with varicella resulting in significant public health burden that could be alleviated through the use of varicella vaccination. Differences observed between countries possibly reflect treatment guidelines, healthcare resource availabilities and physician practices.

Evaluation of a Novel Field Expedient Musculoskeletal Readiness Screening Tool in an Army Basic Training Population.

Musculoskeletal injuries present a significant challenge to military readiness accounting for over 29% of ambulatory medical visits and 25 million limited duty days across the U.S. Army. Although U.S. Military Health Systems perform periodic general health and deployment assessments, there is no validated tool to determine when a service member is at increased risk of sustaining a musculoskeletal injury. 292 U.S. Army basic training recruits completed a novel injury screening test called the Musculoskeletal Readiness Screening Tool (MRST). It consisted of six separate physical movements and asked one question regarding perceived risk of personal injury. The injury surveillance period covered the duration of the basic training program lasting from 9 to 20 weeks. An independent t test was performed to assess for differences in composite MRST scores between those who sustained an injury and those who did not. A Receiver Operator Characteristic curve analysis was completed to determine if an appropriate cutoff score existed to predict increased likelihood for sustaining an injury within this cohort. Our results indicate that the difference in mean composite score between injured (n = 143) and noninjured subjects fell just short of being significantly different (p = 0.053). The MRST is most specific with a cutoff score of 6 (out of a maximum score of 12) at 0.89 (95% confidence interval: 0.82, 0.93). Those scoring less than or equal to 6 on the screening tool were 2.05 times (95% confidence interval: 1.07, 3.9) as likely to sustain an injury as those scoring greater than 6. Additionally, the results indicate that the test can be applied to both male and female trainees, as scores were not significantly different between the sexes. The MRST shows potential as a tool for identifying service members at higher risk for sustaining a musculoskeletal injury. Further research is needed to assess the validity, reliability, and responsiveness of this novel screening tool.

Patient and family empowerment as agents of ambulatory care safety and quality

Since publication of To Err is Human: Building a Safer Health System ,1 consideration of medical errors and injuries has broadened beyond hospital-based harms to patient experiences of harm in...

The non-silent epidemic: low back pain as a primary cause of hospitalisation.

Low back pain (LBP) is the most common cause of pain in adults and the second health condition that prompts patients to seek ambulatory medical care visits. To analyse the impact of LBP on hospitalisations in healthcare facilities within the official subsector in Argentina between 2006 and 2010. Discharges in which the original diagnosis had been either adult LBP or lumbosciatica were assessed. The data comprised age, gender, province of residence, average length of stay (LOS) in the hospital, intra-hospital death, and the Provincial Human Development Index (PHDI). 17,859 discharges had an original diagnosis of LBP and 10,948 of lumbosciatica, which jointly accounted for 18.7 % of all the discharges documented for Diseases of Osteomuscular System and Connective Tissue (DOMS). Hospital discharges of female patients represented 53.7 %. The average age upon admission was 47.7 years in men versus 47.9 in women. The average LOS was slightly higher in men (4.2 vs. 3.8 days, p 0.01). In provinces with a PHDI below the national average, a surgical procedure was performed in 3.1 % of the discharges versus 4.1 % in the provinces with a PHDI above the national average (p < 0.001). LBP was the most frequent cause of hospitalisation due to DOMS. It occurred with a slightly higher frequency in women and prompted short hospitalisations. A surgical procedure was carried out during hospitalisation in very few cases, but the percentage of surgeries during hospitalisation was higher in provinces with a PHDI above the national average.

Pediatric advance directives: parents' knowledge, experience, and preferences.

To explore parents' and caregivers' experience, knowledge, and preferences regarding advance directives (ADs) for children who have chronic illness. We conducted a prospective, cross-sectional survey of parents and caregivers of children who have chronic illness. During ambulatory medical visits, participants were asked about previous AD experience and knowledge, future preferences regarding AD discussions, their child's past and current health status, and family demographics. Among 307 participants surveyed, previous AD experience was low, with 117 (38.1%) having heard of an AD, 54 (17.6%) having discussed one, and 77 (25.1%) having known someone who had an AD. Furthermore, 27 (8.8%) participants had an AD or living will of their own, and 8 (2.6%) reported that their chronically ill child had an AD. Previous AD knowledge was significantly more likely among parents and caregivers who had a college degree than those who did not have a high school diploma, yet significantly less likely among primarily Spanish-speaking parents and caregivers than those primarily English-speaking. Interest in creating an AD for the child was reported by 151 (49.2%) participants, and was significantly more likely among families who had more frequent emergency department visits over the previous year. The limited AD experience and knowledge of parents and caregivers of children who have chronic illness and their interest in creating an AD suggest an unmet need among families of children who have chronic illness, and an opportunity to enhance communication between families and medical teams regarding ADs and end-of-life care.

Trialing to Pain Control: A Grounded Theory

The aim of this study was to examine the basic social psychological process of managing inadequately relieved pain in adults. Transcribed data from 23 ambulatory medical visits of adults with pain and interviews with four practitioners and four patients with pain were analyzed using constant comparative analysis. The basic problem was perception of running out of treatment options. Trialing was the process used to resolve the problem and consisted of four phases: finding the right practitioner, initiating the trial, adjusting treatments, and continuing to monitor with the patient taking control over the pain. Failure to achieve control over pain occurred when providers were unclear or failed to listen or when patients disagreed about treatment. Improving patient-provider communication may enhance trialing.

When Does an Episode of Care for Cancer Begin?

Little is known about the medical care resources devoted to diagnosing and treating cancer-related symptoms before a definitive cancer diagnosis. Previous research using SEER-Medicare data to measure incremental costs and utilization associated with cancer started with the date of diagnosis. We hypothesized that health care use increases before diagnosis of a new primary cancer. We used a longitudinal case-control design to estimate incremental medical care utilization rates. Cases were 121,293 persons enrolled between January 2000 and December 2008 with ≥1 primary cancers. We selected 522,839 controls randomly from among all health plan members who had no tumor registry evidence of cancer before January 2009, and we frequency matched controls to cancer cases on a 5:1 ratio by age group, sex, and having health plan eligibility in the year of diagnosis of the index cancer case. Utilization data were extracted for all cases and controls for the period 2000 to 2008 from standardized distributed data warehouses. To determine when and the extent to which patterns of medical care use change preceding a cancer diagnosis, we compute hospitalization rates, hospital days, emergency department visits, same-day surgical procedures, ambulatory medical office visits, imaging procedures, laboratory tests, and ambulatory prescription dispensings per 1000 persons per month within integrated delivery systems. One- to 3-fold increases in monthly utilization rates were observed during the 3 to 5 months before a cancer diagnosis, compared with matched noncancer control groups. This pattern was consistent for both aged and nonaged cancer patients. Aged cancer patients had higher utilization rates than nonaged cancer patients throughout the year before a cancer diagnosis. The prediagnosis phase is a resource-intensive component of cancer care episodes and should be included in cost of cancer estimates. More research is needed to determine whether reliable prognostic markers can be identified as the start of a cancer episode before a pathology-based diagnosis.

Trialing to pain control: a grounded theory study

The purpose of this research was to examine from a new perspective the basic problem and the social psychological process involved in managing inadequately relieved chronic pain in adults. Glaser’s grounded theory approach was used. Data included transcripts from ambulatory medical visits of 23 older adults with osteoarthritis pain and their five physicians, interviews with four pain management experts, and four adults with pain. Constant comparative analysis was used until the core variable emerged that linked the data together to form the emerging theory.

The Effect of a Spanish Virtual Pain Coach for Older Adults: A Pilot Study

To pilot test the effects of a virtual pain coach on ambulatory Spanish-speaking older adults with pain from osteoarthritis. A randomized, controlled design was used. Eighteen Spanish-speaking older adults were randomly assigned to the virtual pain coach and pain communication education group, or to the pain communication education-only group. All participants viewed the pain communication videotape. Participants in the virtual pain coach group practiced talking about their osteoarthritis pain with the virtual pain coach. Immediately after the respective intervention, participants had their ambulatory medical visit. Pain intensity and pain interference with activities were measured with the Brief Pain Inventory, and depressive symptoms were measured with the Beck Depression Inventory II at baseline and 1 month later. No significant group difference emerged for pain intensity, pain interference with activities, or depressive symptoms 1 month later. More older adults in the virtual pain coach group reported a change from nonuse to use of opioids at 1 month, 50% vs 0% of the education only group, Fisher's exact test, P = 0.023. Preliminary data indicate that the Spanish virtual pain coach might assist Spanish-speaking older adults to talk with their practitioner about their osteoarthritis pain and obtain opioid treatment changes, but that pain and depressive symptoms continue unchanged 1 month later. Additional refinement and testing is required for the Spanish-speaking virtual pain coach to determine acceptability and outcomes for assisting Spanish-speaking older adults to communicate about their pain with their primary care practitioner.

Older Adults' Pain Communication During Ambulatory Medical Visits: An Exploration of Communication Accommodation Theory

The purpose of this descriptive secondary analysis was to explore the use of Communication Accommodation Theory as a framework to examine pain communication strategies used by older adults and their primary care practitioners during medical ambulatory care visits. Ambulatory medical visits for 22 older adults with moderate or greater osteoarthritis pain were audiotaped, transcribed verbatim, and coded by two independent raters for six a priori communication strategies derived from the attuning strategies of Communication Accommodation Theory: 1) patient selecting the pain topic; 2) patient taking a turn; 3) patient maintaining focus on the pain topic; 4) practitioner using an open-ended question without social desirability to start the pain discussion; 5) practitioner encouraging the patient to take a turn by asking open-ended questions; and 6) practitioner interruptions. The majority of practitioners did not start the pain discussion with an open-ended question, but did not interrupt the older adults as they discussed their pain. Five (22.7%) of the older adults did not discuss their osteoarthritis pain during the ambulatory medical visit. The majority of patients took their turn during the pain discussion, but did not maintain focus while describing important osteoarthritis pain information to their practitioner. Practitioners might assist older adults to communicate more information about their pain by initiating the pain discussion with an open-ended pain question. Older adults might provide more pain information to their practitioner by staying on the pain topic until they have completed all of the pain information they wish to discuss with the practitioner.

Comparative Cost Analysis of Housing and Case Management Program for Chronically Ill Homeless Adults Compared to Usual Care

Objective. To assess the costs of a housing and case management program in a novel sample—homeless adults with chronic medical illnesses.Data Source. The study used data from multiple sources: (1) electronic medical records for hospital, emergency room, and ambulatory medical and mental health visits;(2) institutional and regional databases for days in respite centers, jails, or prisons;and (3) interviews for days in nursing homes, shelters, substance abuse treatment centers, and case manager visits. Total costs were estimated using unit costs for each service.Study Design. Randomized controlled trial of 407 homeless adults with chronic medical illnesses enrolled at two hospitals in Chicago, Illinois, and followed for 18 months.Principal Findings. Compared to usual care, the intervention group generated an average annual cost savings of (?)$6,307 per person (95 percent CI: ?16,616, 4,002; p = .23). Subgroup analyses of chronically homeless and those with HIV showed higher per person, annual cost savings of (?)$9,809 and (?)$6,622, respectively.Results were robust to sensitivity analysis using unit costs.Conclusion. The findings of this comprehensive, comparative cost analyses demonstrated an important average annual savings, though in this underpowered study these savings did not achieve statistical significance.

Comparative Cost Analysis of Housing and Case Management Program for Chronically Ill Homeless Adults Compared to Usual Care

To assess the costs of a housing and case management program in a novel sample-homeless adults with chronic medical illnesses. The study used data from multiple sources: (1) electronic medical records for hospital, emergency room, and ambulatory medical and mental health visits; (2) institutional and regional databases for days in respite centers, jails, or prisons; and (3) interviews for days in nursing homes, shelters, substance abuse treatment centers, and case manager visits. Total costs were estimated using unit costs for each service. Randomized controlled trial of 407 homeless adults with chronic medical illnesses enrolled at two hospitals in Chicago, Illinois, and followed for 18months. Compared to usual care, the intervention group generated an average annual cost savings of (-)$6,307 per person (95 percent CI: -16,616, 4,002; p=.23). Subgroup analyses of chronically homeless and those with HIV showed higher per person, annual cost savings of (-)$9,809 and (-)$6,622, respectively. Results were robust to sensitivity analysis using unit costs. The findings of this comprehensive, comparative cost analyses demonstrated an important average annual savings, though in this underpowered study these savings did not achieve statistical significance.

Sociodemographic and geographic characteristics associated with patient visits to osteopathic physicians for primary care.

BackgroundHealth care reform promises to dramatically increase the number of Americans covered by health insurance. Osteopathic physicians (DOs) are recognized for primary care, including a "hands-on" style with an emphasis on patient-centered care. Thus, DOs may be well positioned to deliver primary care in this emerging health care environment.MethodsWe used data from the National Ambulatory Medical Care Survey (2002-2006) to study sociodemographic and geographic characteristics associated with patient visits to DOs for primary care. Descriptive analyses were initially performed to derive national population estimates (NPEs) for overall patient visits, primary care patient visits, and patient visits according to specialty status. Osteopathic and allopathic physician (MD) patient visits were compared using cross-tabulations and multiple logistic regression to compute odds ratios (ORs) and 95% confidence intervals (CIs) for DO patient visits. The latter analyses were also conducted separately for each geographic characteristic to assess the potential for effect modification based on these factors.ResultsOverall, 134,369 ambulatory medical care visits were surveyed, representing 4.6 billion (NPE) ± 220 million (SE) patient visits when patient visit weights were applied. Osteopathic physicians provided 336 million ± 30 million (7%) of these patient visits. Osteopathic physicians provided 217 million ± 21 million (10%) patient visits for primary care services; including 180 million ± 17 million (12%) primary care visits for adults (21 years of age or older) and 37 million ± 5 million (5%) primary care visits for minors. Osteopathic physicians were more likely than MDs to provide primary care visits in family and general medicine (OR, 6.03; 95% CI, 4.67-7.78), but were less likely to provide visits in internal medicine (OR, 0.37; 95% CI, 0.24-0.58) or pediatrics (OR, 0.21; 95% CI, 0.11-0.40). Overall, patients in the pediatric and geriatric ages, Blacks, Hispanics, and persons in the South and West were less likely to utilize DOs, although there was some evidence of effect modification according to United States Census region.ConclusionsHealth care reform provides unprecedented opportunities for DOs to reach historically underserved populations and to overcome the "pediatric primary-care paradox."

Challenging Cough Cases: A New Frontier in Otolaryngology

Program Description: Both acute and chronic cough are responsible for a significant portion of all ambulatory medical visits annually (about 3%), over-the-counter self-medication expenses in excess of $3.6 billion in the United States, and impaired quality of life. According to 2007 data, there were more than 27 million visits to all physicians for cough, but that same year otolaryngologists saw a total of only 17 million visits for all diagnoses. This suggests a large unmet need for otolaryngologists to participate in the care of these patients. The diagnosis of cough can be simple or profoundly challenging, and it may be a sentinel indicator of severe underlying disease. The list of diseases that may induce cough is growing, along with an appreciation of their interrelations. For example, the Unified Airway concept supports our long-held observation that the upper and lower airway diseases are closely related. There is also a spectrum of overlapping asthmatic, non-asthmatic, and suppurative pulmonary disease. Gastroesophageal reflux (both distal and proximal LaryngoPharyngeal Reflux), along with neurologic reflexes and aspiration are similarly important. And the complex interplay of neurologic reflexes for cough in the brainstem may result in paradoxical vocal fold motion and disordered breathing. Otolaryngologists are playing an increasingly important role in the multidisciplinary evaluation of these challenging patients, and mastering many procedures associated with cough patients. The spectrum of medical specialists also includes pulmonology and chest physicians, allergy and immunology, gastroenterology, neurology, cardiology, infectious disease, speech and swallowing pathologists, as well as psychiatry. This miniseminar will involve the use of case presentations, panel discussion and audience participation to emphasize evidence-based practice and “state-of-the-art.” Controversial areas will include the inter-relatedness of the disease, the role of speech therapy in disordered breathing, and the importance of early diagnosis in value-based healthcare. Educational Objectives: 1) Learn the spectrum of common and uncommon causes of chronic cough. 2) Understand evidence-based treatment guidelines in the evaluation and treatment of these patients. 3) Be prepared to participate in interdisciplinary discussion of these patients at their home institution.

Cough

Both acute and chronic cough are responsible for a significant portion of all ambulatory medical visits annually, over-the-counter self-medication expenses in excess of $3.6 billion in the United States, and impaired quality of life. Yet otolaryngologists only see a small portion of these patients. The diagnosis of cough can be simple or profoundly challenging, and it may be a sentinel indicator of severe underlying disease. The list of diseases that may induce cough is growing, along with an appreciation of their interrelations. These include upper and lower airway diseases, related through the unified airway concept. Gastroesophageal reflux, aspiration, neurologic reflexes, tumor, and systemic diseases are also important. Otolaryngologists are playing an increasingly valuable role in the multidisciplinary approach to these challenging cough patients and master many procedures associated with their evaluation and treatment. There are also leadership opportunities in building coordinated teams to further patient care.