Appointment Availability Research Articles

Impact of the SARS-CoV-2 pandemic on the course and treatment of appendicitis in the pediatric population

SARS-CoV-2 is a highly contagious virus causing mainly respiratory track disease called COVID-19, which dissemination in the whole world in the 2020 has resulted in World Health Organisation (WHO) announcing the pandemic. As a consequence Polish Government made a decision to go into a lockdown in order to secure the population against SARS-CoV-2 outbreak what had its major influence on the Polish Health Care System. All of the social and medical factors caused by the pandemic might influence children’s health care, including urgent cases. The aim of this survey was the analysis of medical charts with focus on the course and results of surgical treatment of children who underwent appendectomy before and during the COVID-19 pandemic. Material and methods: We performed analysis of charts of 365 subjects hospitalized in the Pediatric Surgery Department from 1st January 2019 to 31st December 2020 because of acute appendicitis. Patients were divided into two groups—those treated in 2019—before pandemic outbreak, and those treated in 2020 in the course of pandemic. Results: the most common type of appendicitis was phlegmonous (61% of cases in 2019 and 51% of cases in 2020). Followed by diffuse purulent peritonitis (18% of cases in 2019 vs 31% of cases in 2020), gangrenous (19% of cases in 2019 vs 15% of cases in 2020) and simple superficial appendicitis (1% of cases in 2019 vs 3% of cases in 2020). There was statistically significant difference in the length of hospitalization: in 2019 the mean length of hospi-talization was 4.761 vs 5.634 in 2020. Laparoscopic appendectomy was performed more frequently before the COVID period (63% of cases treated in 2019 vs 61% of cases treated in 2020). In the pandemic year 2020, there was double increase in the number of conversion from the laparoscopic approach to the classic open surgery. In the year 2019 drainage of abdominal cavity was necessary in 22% of patients treated with appendectomy, in 2020 the amount of cases threated with appendectomy and drainage increased to 32%. Conclusions: fear of being infected, the limited availability of appointments at General Practitioners and the new organisation of the medical health care system during pandemic, delay proper diagnosis of appendicitis. Forementioned delay leads to higher number of complicated cases treated with open appendectomy and drainage of abdominal cavity, higher number of conversions from the laparoscopic to classic open technique, and longer hospitalization of children treated with appendectomy in the year of pandemic.

COVID-19-Related Disruptions to HIV Testing and Prevention Among Young Sexual Minority Men 17-24 Years Old: A Qualitative Study Using Synchronous Online Focus Groups, April-September 2020.

Prior research has highlighted the impact of the COVID-19 pandemic on HIV prevention services within the U.S., but few studies have explored this impact through an exploratory, qualitative lens. In this study, we sought to highlight the voices of young sexual minority men (YSMM) 17–24 years old and explored the perceived impact of the pandemic on HIV prevention among a diverse, nationwide sample of YSMM who participated in synchronous online focus group discussions between April and September 2020. Forty-one YSMM described the negative effects of the COVID-19 pandemic on HIV testing and prevention services, including limited and disrupted access to HIV testing, HIV pre-exposure prophylaxis (PrEP), and HIV post-exposure prophylaxis. COVID-19-related challenges were compounded by ongoing, pre-COVID-19 barriers experienced by YSMM in the U.S. For instance, many YSMM relocated back home with family, causing men to avoid HIV prevention services for fear of outing themselves to relatives. YSMM also worried about placing their family at increased risk of COVID-19 by attending clinical appointments. YSMM who did seek HIV prevention services, including access to PrEP, experienced significant barriers, including limited appointment availability and services not tailored to YSMM. Further efforts are needed to support YSMM re-engaging in HIV prevention during and after the COVID-19 era.

Hemophilia in Patients 50 Years or Older: Quality of Life, Health Maintenance, Cancer Screening and COVID19

INTRODUCTION: Major progress has been made in treatment of patients with hemophilia over the last 30 or 40 years. Factor replacement, eliminating HIV and hepatitis C transmission, and more recently, longer-acting coagulation factors and immune treatments play a role in allowing patients with hemophilia to experience a longer and healthier life. Previous studies show that invasive procedures like colonoscopies, bronchoscopies or biopsies can safely be performed in patients with hemophilia if an appropriate factor replacement is given. However, because of their risk of bleeding, patients with hemophilia may be reluctant to undergo such invasive procedures or get recommended health maintenance, and these fears may have been worsened by the outbreak of COVID19. Therefore, we wondered if older patients with hemophilia have been impacted by the COVID19 pandemic and have received the recommended vaccinations and cancer screenings.METHODS: The data for this study originates in the hemophilia clinics of two academic centers in Kentucky (University of Louisville and University of Kentucky). IRB approval was obtained in both institutions. Surveys were mailed or emailed to patients 50 years of age or older in our database. Follow-up phone calls were made to patients who did not respond. The surveys had 17 health related questions focusing on general well-being, pain, smoking, cancer screening, vaccinations and COVID19. The original survey was performed between 11/2020 and 3/2021 and COVID19 vaccination status was updated in 7/2021. Overall, 50 patients in our database met the study criteria (hemophilia and age 50 years or older) and 36 responded (72%). Some patients did not answer all questions.Patient details are given in Table 1. Median age was 61 years, most patients had mild to moderate hemophilia, three patients were positive for HIV (all with a negative viral load), and 12 had been infected with hepatitis C. Questions related to the impact of COVID19 explored anxiety of leaving the house, meeting with other people, availability of medical appointments, and getting necessary medications. Patients were asked if they received an influenza vaccination and, if older than 60 years, if they had received a pneumonia vaccination.RESULTS: Overall, most patients reported a good quality of life (Table 2). Nevertheless, most were often or always in pain. About half of the patients were on opioid pain medication. A minority took only over the counter pain medication or no pain medication. 57% of respondents had received both vaccinations for COVID19, two-thirds of the unvaccinated planned to get it. 55% of respondents had undergone a colonoscopy in the previous 5 years. Only 18% identified themselves as current smokers. Few men had undergone screening for prostate cancer. Finally, 5 of 32 patients reported a previous diagnosis of cancer (3 patients with localized skin cancer, 2 patients with head and neck cancers).CONCLUSIONS: Quality of life in patients with hemophilia is self-reported as good or excellent in most older patients. However, chronic pain problems persist and are not always sufficiently controlled. One reason may be that many of our patients did not have consistent factor replacements early in their life. Only a minority of patients reported a psychological or physical impact of the COVID19 lockdown. Most patients as of June or July 2021 have been vaccinated against COVID19, however this is probably lower than in an age-matched group. Mayo Clinic's vaccine tracker reported a vaccination rate of 92.3% for the 65 and older age group in Kentucky (as of July 31 st of 2021). The rate of influenza vaccination is probably comparable to rates in other rural communities. The same applies to cancer screening by colonoscopy and PSA screening. The rate of smoking of 18% is relatively low but may suffer from under-reporting. Overall, health maintenance in older patients with hemophilia appears acceptable but can certainly be improved. Limitations of our study are small sample size and that most patients have mild to moderate hemophilia. We plan to expand our study to other centers to get more insight into health issues in older patients with hemophilia. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Improving Primary Care Behavioral Health Integration in an Academic Internal Medicine Practice: 2-Year Follow-Up.

This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Efforts were informed by a modified version of the validated Level of Integration Measure, sent to all faculty and staff annually. At baseline, results indicated that the domains of systems integration, training, and integrated clinical practices had the greatest need for improvement. Over the 2 years, the authors increased availability of behavioral medicine appointments, improved depression screening processes, offered behavioral health training for providers, disseminated clinical decision support tools, and provided updates about integration progress during clinic meetings. Follow-up survey results demonstrated that physicians and staff perceived improvements in integration overall and in targeted domains. However, the main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.

Investigating the impact of distance on the use of primary care extended hours.

IntroductionPoor access to general practice services has been attributed to increasing pressure on the health system more widely and low satisfaction among patients. Recent initiatives in England have sought to expand access by the provision of appointments in the evening and at weekends. Services are provided using a hub model. NHS national targets mandate extended opening hours as a mechanism for increasing access to primary care, based on the assumption that unmet need is caused by a lack of appointments at the right time. However, research has shown that other factors affect access to healthcare and it may not simply be appointment availability that limits an individual’s ability to access general practice services.ObjectivesTo determine whether distance and deprivation impact on the uptake of extended hours GP services that use a hub practice model.MethodsWe linked a dataset (N = 25,408) concerning extended access appointments covering 158 general practice surgeries in four Clinical Commissioning Groups (CCGs) to the General Practice Patient Survey (GPPS) survey, deprivation statistics and primary care registration data. We used negative binomial regression to estimate associations between distance and deprivation on the uptake of extended hours GP services in the Greater Manchester City Region. Distance was defined as a straight line between the extended hours provider location and the patient’s home practice, the English Indices of Multiple Deprivation were used to determine area deprivation based upon the home practice, and familiarity was defined as whether the patient’s home practice provided an extended hours service.ResultsThe number of uses of the extended hours service at a GP practice level was associated with distance. After allowing for distance, the number of uses of the service for hub practices was higher than for non-hub practices. Deprivation was not associated with rates of use.ConclusionThe results indicate geographic inequity in the extended hours service. There may be many patients with unmet need for whom the extension of hours via a hub and spoke model does not address barriers to access. Findings may help to inform the choice of hub practices when designing an extended access service. Providers should consider initiatives to improve access for those patients located in practices furthest away from hub practices. This is particularly of importance in the context of closing health inequality gaps.

176 Emergency Department Visits for Low-Acuity Conditions and Primary Care: Substitutes or Complements in Medicaid?

Historically, emergency departments (ED) evolved to serve as a substitute for primary care (PC), especially among populations that tend to lack PC access, such as the uninsured and Medicaid enrollees. Although the Affordable Care Act (ACA) policy makers aimed to decrease ED visits by expanding insurance coverage and thus PC access, the ACA Medicaid expansion increased ED visit rate among patients with Medicaid coverage. Additionally, the substitution assumption is under scrutiny, given increasing evidence on referrals from PC providers to the ED, which would indicate complementarity instead. We empirically tested whether primary care and ED visits for primary care treatable (PCT) conditions are substitutes or complements. Using consumer choice theory from economics, we developed a testable model that differentiates between substitution and complementarity between PC and ED visits. In both cases, ED visit rates are represented as a spline function, with an estimated knot, of PC supply; negative slope on the left spline indicates substitution and positive slope indicates complementarity. We used non-linear least squares to estimate the function. We used a unique data linkage from New York state: county-month level Medicaid managed care enrollment and county-quarter level provider data from NY Department of Health, and ED visit data from SPARCS (9/2014-9/2015) (N=793). In selecting covariates and fixed effects, we assessed model fit. The best- fitting model specification includes county fixed effects and three time-varying covariates: poverty rate, unemployment rate, and percent population in Medicaid managed care. Bootstrap standard errors were calculated. ED visits for PCT conditions by population aged 0-64 y.o. were included in the analysis. Using the NYU ED classification algorithm, we identified conditions that are 100% PCT, based on both the principal and admitting diagnoses. ED and PC visits were substitutes for one another statewide (slope coefficient -0.28, P<0.05), but served as complements during nights and weekends in highly urban and poorer counties (slope coefficient 0.63, P<0.01; population in poverty 21.7-31.5%). PC physician supply was associated with decreased ED use in rural counties during the day (-0.11, P<0.10) but increased ED use during nights and weekends in highly urban (0.23, P<0.01) and richer counties (population in poverty 5.8-9.0%). These relationships reversed when advanced practice providers (APPs) were considered instead (0.19, P<0.05 during the day across all counties; -0.24, P<0.01 during nights and weekends in highly urban and in richer counties, ie, population in poverty 5.8-11.3%). While the ED is used as a substitute for primary care during the day, complementarity at night and on weekends indicates increasing prominence of referrals, the rates of which appear to vary across areas. While during the day, higher PC physician supply appears to divert Medicaid enrollees from the ED, PC APP supply contributes to more ED use for low-acuity conditions. Policy makers should not assume that increasing PC access will necessarily reduce low-acuity ED visits. More nuanced understanding suggests that policies to decrease low-acuity ED use via PC access improvements in Medicaid will be more effective if they focus on increasing actual appointment availability, ideally by primary care physicians, in areas with low primary care supply.

Client perspectives on choice of abortion method in England and Wales

IntroductionThe National Institute for Health and Care Excellence, the Royal College of Obstetricians and Gynaecologists and the World Health Organization recommend that services provide a choice between medical and surgical...

Hospital Selection Factors of Sleep Disorder: Sleep Apnea Versus Other Sleep Disorders

Objectives: The hospital selection factor is the criterion based on the judgment of the patients’ decision process. We investigated the hospital selection factors of patients with sleep disorders and compared that for patients with sleep apnea and other sleep disorders. Methods: This is a questionnaire-based cross-sectional study that evaluated patients with a sleep disorder at the sleep unit of a tertiary referral center. We investigated the patients’ demographic information, occupational status, diagnosis of sleep disorders, and hospital-related and patient-related factors associated with hospital selection. Results: A total of 138 patients with a sleep disorder were analyzed. Internet information was the primary data source for sleep apnea patients to select a hospital, while it was acquaintances for patients with other sleep disorders. None with sleep apnea gathered information from broadcast or print media. Patients gave the highest score for the least waiting time and recency of the hospital’s facility. Unlike patients with other sleep disorders, those with sleep apnea valued the hospital’s popularity, accessibility, availability of appointments at desired dates, and medical expense benefits. Conclusions: This is the first study to analyze the hospital selection factors of patients with sleep disorders in South Korea. This study might improve the sleep medication as well as the medical system by revealing the medical use behavior of patients with sleep disorders.

What is the current practice for managing patients with chronic limb-threatening ischaemia in vascular surgery services? A survey of UK vascular surgeons.

The Vascular Society of Great Britain and Ireland (VSGBI) Peripheral Arterial Disease Quality Improvement Framework (PAD QIF) stipulates targets for managing patients with chronic limb-threatening ischaemia (CLTI); however, it is unknown whether these are achievable. This survey aims to evaluate contemporary practice for managing CLTI in the UK. A questionnaire was developed in conjunction with the VSGBI to survey the management of CLTI and canvass opinions on the PAD QIF. The survey was distributed to all consultant members of the VSGBI and through a targeted social media campaign. Forty-seven consultant vascular surgeons based at 36 arterial centres across the UK responded (response rate from arterial centres = 46%). Only 14.3% of centres provided outpatient consultation within the target of seven days from referral, with only one centre providing revascularisation within the target of seven days from consultation. For inpatient management, 31.6% provided surgical and 23.8% endovascular revascularisation within the target of three days from assessment. While 60% of participants believe the PAD QIF's 5-day 'admitted care' pathway is achievable, only 28.6% thought the 14-day 'non-admitted care' pathway was feasible. Challenges to meeting these targets include the availability of theatre space and angiography lists, and availability of outpatient appointments for patient assessment. The opinion of UK vascular surgeons indicates that achieving the targets of the PAD QIF represents a major challenge based upon current services. Adapting existing services with a greater focus on providing an 'urgent' model of care may help to potentially overcome these challenges.

Recommendations from parents, administrative staff and clinicians to improve paediatric ambulatory appointment scheduling

Stakeholders can provide valuable input to improve scheduling paediatric ambulatory clinic appointments, a complex process that requires effective planning and communication between parents, administrative staff and clinicians. The purpose of our study was to characterize recommendations from parents, administrative staff and clinicians to improve paediatric ambulatory appointment scheduling. Conducted between February 2018 and January 2019, this qualitative study was guided by qualitative description. Data collection was completed using focus groups with three stakeholder groups: parents, administrative staff and clinicians. Participants provided recommendations to optimize paediatric ambulatory appointment scheduling at the Stollery Children's Hospital in Edmonton, Alberta, Canada. Focus group data were transcribed verbatim and analysed using manifest inductive content analysis. Forty-six participants (mean age: 42.7; 87% female) participated in 12 focus groups. Parents (n = 11), administrative staff (n = 22) and clinicians (n = 13) made recommendations that were organized into two categories: appointment triaging and arranging. Triaging recommendations were related to appointment availability (e.g. providing alternatives to cancelling clinics with short notice) and waitlist management (e.g. developing clear and consistent policies regarding information flow and communication between clinics and administrative staff). Appointment arranging recommendations referred to booking (e.g. directly involving parents in the booking process), reminders (e.g. using text message reminders) and attendance (e.g. providing parents with a single point of contact who can provide the correct information about late and cancellation policies). Recommendations were similar across stakeholder groups. Our findings showed congruent recommendations across stakeholder groups to address challenges with scheduling ambulatory appointments, many of which have the potential to be modified. Experimental research and quality improvement initiatives are needed to determine the feasibility, acceptability and effectiveness of stakeholder recommendations to improve triaging and scheduling paediatric ambulatory appointments.

Student, Faculty, and Graduate Teaching Assistant Perceptions of Support Provided by a Graduate Student Writing Centre

The purpose of this mixed-methods study was to identify key factors in a discipline-specific, self-access graduate writing centre that both contribute to student success and that indicate needed improvements. The centre is located in a graduate education program at a university in Canada. Findings indicate the centre contributes to student success most directly by helping students improve their writing, which leads to an overall sense of confidence and engagement. Relationships with other students were also enhanced and found to be important. Faculty similarly noted that the improvements in writing and the strengthening of the graduate student culture were important gains. Graduate teaching assistants working in the centre said they benefited from improvements with their writing, which they linked to supporting students, as well as personal gains in their instructional skills. Suggested improvements included increasing appointment availability, adding workshops on new topics, increasing the availability of workshops and events, and increasing interaction between students and faculty at social events. These results indicate that providing targeted supports led by students but guided by faculty input and oversight can increase graduate student success and benefit graduate programs in general.

Care Barriers for Patients With Nonsyndromic Orofacial Clefts in Saudi Arabia: A Cross-Sectional Study.

To evaluate the barriers faced by patients with nonsyndromic orofacial clefts (NSOFC) throughout their treatment course in Saudi Arabia. A cross-sectional study. Eleven different governmental health care centers across Saudi Arabia. Patients: Records of pediatric patients with NSOFC. A questionnaire with multiple validation stages was designed to assess the barriers in care of these patients through telephonic interviews with the parents or guardians of patients with NSOFC. We identified 3 care-barrier-related factors: (1) geographic accessibility, (2) appointment availability and accessibility, and (3) scheduling-related barriers. Overall, 240 participants of both sexes, with orofacial cleft of various types and with various demographic characteristics (residence, family monthly income, and caregiver level of education) were included. The highest mean score of care barriers was reported for scheduling-related barriers. Overall, 186 individuals reported sometimes/often not receiving the required medical care for the following reasons: scheduling difficulties (89%; 37.1%), prolonged waiting room time (40%; 16.7%), and transportation difficulties (36%; 15.0%). A linear regression showed that parents cited late appointments as the main reason for patients with NSOFC not receiving adequate medical care. Care-barrier factors were significantly related to gender (P = .035), patient age (P < .001), place of residency (P < .001), and caregiver's level of education (P = .015). Gaps in the health care system directly related to common care barriers need to be addressed to ensure adequate care for patients with NSOFC.

312-OR: Comparison of Processes of Care and Acute Care Utilization for Medicaid Enrollees with Type 2 Diabetes in Federally Qualified Health Centers vs. Other Sites of Primary Care

Background: Adults with type 2 diabetes and Medicaid insurance are a highly vulnerable population. Despite the vital role of primary care for diabetes management, few studies have examined how the type of primary care setting affects quality of care for this population, and existing studies have not examined data across the US. Since federally qualified health centers (FQHCs) are the primary care safety net for many Medicaid patients, we compared process of care outcomes and acute care utilization for non-elderly adult Medicaid enrollees with type 2 diabetes at FQHC vs. non-FQHC primary care settings. Methods: We analyzed 2012 Medicaid fee-for-service and managed care claims data in all 50 states and DC in order to compare 8 processes of care and acute care utilization for patients receiving care at FQHCs (N=121,977) vs. non-FQHCs (N=700,401). We used propensity score overlap weighting to obtain groups balanced on covariates, then used generalized estimating equation models to compare the two groups. Results: FQHC patients had 2.6-3.6% lower rates of each measure compared to non-FQHC patients, with the exception of a higher rate of diabetes education (relative risk, 1.09 [95% CI, 1.03-1.16]). Compared to non-FQHC patients, FQHC patients had more overall (incident rate ratio, 1.06 [1.05-1.07]) and diabetes-related emergency department (ED) visits (1.10 [1.08-1.13]), but fewer overall (0.87 [0.86-0.88]) and diabetes-related hospitalizations (0.79 [0.77-0.81]). Conclusions: Our findings suggest that Medicaid enrollees with type 2 diabetes receiving primary care at FQHCs may have limited access to both preventative and urgent diabetes care. FQHC patients with diabetes may visit EDs more frequently as a result of limited appointment availability or access to specialists at FQHCs. These results underscore the need for increased support and funding for Medicaid patients with type 2 diabetes, especially in FQHCs. Disclosure A. C. Knitter: None. M. Murugesan: None. L. Saulsberry: None. W. Wan: None. R. Nocon: None. E. Huang: None. J. Bolton: None. M. Chin: Advisory Panel; Self; Bristol-Myers Squibb Company. N. Laiteerapong: Other Relationship; Self; American Diabetes Association. Funding Health Resources and Services Administration (HHSH250201300025I); National Institute of Diabetes and Digestive and Kidney Diseases (P30DK092949)

Primary Care Access During the COVID-19 Pandemic: a Simulated Patient Study.

BackgroundPrimary care practices have experienced major strains during the COVID-19 pandemic, such that patients newly seeking care may face potential barriers to timely visits.ObjectiveTo quantify availability and wait times for new patient appointments in primary care and to describe how primary care practices are guiding patients with suspected COVID-19.DesignTrained callers conducted simulated patient calls to 800 randomly sampled primary care practices between September 14, 2020, and September 28, 2020.ParticipantsWe extracted complete primary care physician listings from large commercial insurance networks in four geographically dispersed states between September 10 and 14, 2020 (n=11,521). After excluding non-physician providers and removing duplicate phone numbers, we identified 2705 unique primary care physician practices from which we randomly sampled 200 practices in each region.Main MeasuresPrimary care appointment availability, median wait time in days, and practice guidance to patients suspecting COVID-19 infection.Key ResultsAmong 56% of listed practices that had accurate contact information listed in the directory, 84% offered a new patient in-person or virtual appointment. Median wait time was 10 days (IQR 3–26 days). The most common guidance in case of suspected COVID-19 was clinician consultation, which was offered in 41% of completed calls. Callers were otherwise directed to on-site testing (14%), off-site testing (24%), a COVID-19 hotline (8%), or an urgent care/emergency department (12%), while 2% of practices had no guidance to offer.ConclusionsDespite resource constraints, most reachable primary care practices offered timely new patient appointments as well as direct COVID-19 care. Pandemic mitigation strategies should account for and support the central role of primary care practices in the community-based pandemic response.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06804-7.

Barriers to Care Experienced by Patients Who Inject Drugs During the COVID-19 Pandemic: A Qualitative Analysis.

Objectives:To identify the barriers to accessing health care and social services faced by people who inject drugs (PWID) during the coronavirus disease 2019 (COVID-19) pandemic.Methods:This report is a sub-analysis of a larger qualitative study. Semi-structured interviews were conducted with PWID admitted to an academic medical center from 2017 to 2020 for an invasive injection-related infection. Standard qualitative analysis techniques, consisting of both inductive and deductive approaches, were used to identify and characterize the effects of COVID-19 on participants.Results:Among the 30 PWID interview participants, 14 reported barriers to accessing health and addiction services due to COVID-19. As facilities decreased appointment availability or transitioned to telemedicine, PWID reported being unable to access services. Social distancing led to isolation or loneliness during hospital stays and in the community. Recovery meetings and support groups, critical to addiction recovery, were particularly affected. Other participants reported that uncertainty and fear of contracting the virus generated changes in behavior that led them to avoid seeking services.Conclusions:COVID-19 has disrupted health systems and social services, leading PWID to experience unprecedented barriers to accessing and maintaining health and addiction services in both inpatient and outpatient settings. Opioid use disorder management must be understood as a holistic process, and a multidisciplinary approach to ensuring comprehensive care, even in the midst of this pandemic, is needed.

Evaluation of the Effects of the COVID-19 Pandemic on Electronic Consultation Use in Primary Care.

Background: Little is known about electronic consultation (e-consult) utilization during the COVID-19 pandemic when health systems rapidly implemented and scaled telehealth alternatives to in-person care. It is also unknown if e-consult utilization during the pandemic replaced or merely deferred the need for a specialty appointment. We evaluated if primary care providers' (PCPs) e-consult utilization and specialists' recommendations for specialty appointments changed after the transition to telemedicine during the COVID-19 pandemic. Methods: This cohort study used an interrupted time series analysis of e-consult utilization in a large, urban academic health care system between December 1, 2019, and June 27, 2020; the post-telemedicine time period began March 15, 2020. The primary outcome measure was the odds of an e-consult ordered during a PCP appointment; the secondary outcome measure was the odds of a specialist recommending a specialty appointment in an e-consult. Results: During 193,263 PCP appointments, 1,318 e-consults were placed to internal medicine subspecialties. Compared to the pre-telemedicine time period, the odds of a PCP ordering an e-consult increased (OR 1.04, 95% CI [1.02-1.07]) and the odds of specialists recommending specialty appointments increased (OR 1.11, 95% CI [1.06-1.15]). Conclusions: E-consult use increased following the transition to telemedicine in the context of the COVID-19 pandemic, suggesting that PCPs consider the e-consult a valuable tool for patient care when there is limited availability of specialty appointments. However, recommendations for specialty appointments following an e-consult also increased, suggesting that the e-consult may not replace the need for a specialty appointment.

Instrument Development and Validation to Assess Care Barriers for Patients in Saudi Arabia with Oral Clefts.

The study objective was to construct and validate a tool to assess, measure, and evaluate the barriers and obstacles that patients with orofacial clefts (OFCs), and their families, face during treatment. The Effective Accessibility and Accommodation subscale, based on the translated Primary Care Assessment Survey and Primary Care Assessment Tool scales, was used as a reference for the questionnaire. A total of 165 parents from three main cleft referral centers in Saudi Arabia were interviewed. Questionnaire content validity was conducted by calculation of a content validity index for each item (I-CVI) as well as for the total scale (S-CVI). Reliability was tested using Cronbach’s alpha. Factor analysis and principal components analysis were performed to determine the factor structure of the instrument. The final questionnaire had nine items. Rating results showed both I-CVI and S-CVI scores of 1 and Cronbach’s alpha was 0.86. There were three factors (geographic accessibility, appointment availability and accessibility, and scheduling-related barriers) with eigenvalues above 1.00, which collectively accounted for 73% of the variance. In conclusion, this tool is valid and reliable to evaluate accessibility and barriers to care of patients with OFCs in Saudi Arabia.

Managing capacity for virtual and office appointments in chronic care.

Patients living with a chronic disease often require regular appointments and treatments. Due to the constraints on the availability of office appointments and the capacity of physicians, access to chronic care can be limited; consequently, patients may fail to receive the recommended care suggested by clinical guidelines. Virtual appointments can provide a cost-effective alternative to traditional office appointments for managing chronic conditions. Advances in information technology infrastructure, communication, and connected medical devices are enabling providers to evaluate, diagnose, and treat patients remotely. In this study, we build a capacity allocation model to study the use of virtual appointments in a chronic care setting. We consider a cohort of patients receiving chronic care and model the flow of the patients between office and virtual appointments using an open migration network. We formulate the planning of capacity needed for office and virtual appointments with a newsvendor model to maximize long-run average earnings. We consider differences in treatment and diagnosis effectiveness for office and virtual appointments. We derive optimal capacity allocation policies and implement numerical experiments. With the model developed, capacity decisions for office and virtual appointments can be made more systematically with the consideration of patient disease progressions.

Association of Secure Messaging with Primary Care In-Person and Telephone Visits Among Veterans: a Matched Difference-in-Difference Analysis.

Secure messaging (SM) between patients and primary care teams has expanded care access but may impact other clinical encounters. To study associations between SM use and primary care in-person and telephone visits in the Veterans Health Administration (VHA). The SM feature of VHA's patient portal, MyHealtheVet, supports asynchronous communication between patients and primary care teams. To study the impact of SM on in-person and telephone visits, two analyses were performed: (1) a retrospective pre-/post-analysis comparing changes after initiating SM use and (2) a difference-in-difference comparison among SM users and non-users 1 year before and after index SM use. Matching to non-users was by primary care team, demographics, and predicted propensity of SM use by Nosos comorbidity score and drive time to clinic. In 2016, 154,053 Veterans initiated SM from all primary care patients (N = 5,891,893); 25,683 were propensity-matched to controls (N = 49,266) from the same primary care team not using SM. Primary care provider in-person visits and telephone contacts between patients and their primary care team were assessed 1 year prior and post index SM. Overall, primary care in-person visits decreased 13.3% (p < 0.0001); telephone visits increased 13.5% (p < 0.0001). In the matched analysis, in-person primary care visits decreased by 16.0% (p < 0.0001) by SM users and 9.9% (p < 0.0001) among controls, resulting in a across-group decrease of 6.1% in-person visits after SM initiation. Telephone visits increased by 11.0% (p < 0.0001) for SM users and 4.5% for controls (p < 0.0001) resulting in an across-group increase of 6.5% telephone visits after SM initiation. Use of SM was associated with decreased in-person visits and increased telephone visits. This may improve clinic appointment availability, while increasing time commitments for providers for non-traditional forms of access.

Perceptions of collaborative care team members on facilitators and barriers to care and glycosylated hemoglobin level as a diabetes quality metric at a federally qualified health center in Texas

ObjectivesFacilitators and barriers to collaborative patient care have been explored in previous studies. Few studies provide information about collaborative care team (CCT) members’ roles in treating patients with diabetes and how CCT members should be evaluated for their contributions to diabetes care. To describe the roles and responsibilities of CCT members at CommUnityCare (CUC), a federally qualified health center in Central Texas; identify the facilitators and barriers affecting referrals to other CCT members within CUC; explore the facilitators and barriers to collaborative patient care at CUC; and assess CCT members’ perceptions of quality metrics for diabetes care. MethodsA cross-sectional design was used. Data was collected by a survey and semistructured interviews of CCT members. The survey (32 questions) assessed roles and responsibilities, including the percentage of time spent on clinic activities, referral criteria, perceptions of quality diabetes care, and facilitators and barriers to care. The interview (32 questions) gathered a description of the CCT member’s role, referral process, and ideas for diabetes quality metrics. Descriptive statistics and content analysis were used for data analysis. ResultsTwenty-two CCT members (4 diagnosticians, 4 clinical pharmacists, 4 behavioral health professionals, 4 registered dietitians, 2 community health workers, and 4 care managers) participated in this study. Co-location (54%) and professional relationships with coworkers (32%) facilitated referrals to other CCT members. Appointment availability (32%) and lack of referral criteria knowledge (27%) were barriers to other CCT member referrals. Seventy-five percent of the dietitians and care managers thought that the glycosylated hemoglobin (A1C) level was a good quality metric for diabetes care, followed by 50% of the clinical pharmacists, 25% of the behavioral health counselors, and 0% of the community health workers and diagnosticians. ConclusionCo-location and professional relationships facilitated referrals to CCT members, whereas lack of CCT member availability and lack of referral criteria knowledge were barriers to CCT referrals. Metrics other than the lowering of the A1C level should be further explored to assess the quality of diabetes care.