Day Of Appointment Research Articles

Implementation of a patient reminder system in Haiti in a socio-political crisis context: evaluation of outcomes

BackgroundIn Haiti, patient’s adherence to treatment and compliance with medical appointments are very challenging due to different local factors. We aimed to assess the effectiveness of a reminder system implemented in health facilities in Haiti in a context of socio-political crisis.MethodsWe used appointment data from patients aged 15 years and older between January 2021 and November 2023 from four healthcare centers in the Port-au-Prince metropolitan area. We performed descriptive analysis, crossing covariates with appointment attendance. We performed Pearson’s Chi-squared test, and multivariate regression analysis using a mixed-effect logistic regression model in order to explore the association between sending reminders and appointment attendance, with and without adjustment for other patient-level covariates.ResultsA total of 14 108 appointments were registered on the reminder systems, with 2 479 (17.6%) attendances. Among those to whom reminders were sent, the number of attendances was 167 (17.4%) for email recipients only, 199 (36.7%) for SMS recipients only, and 19 (42.2%) for both SMS and email recipients – versus 2 094 (16.7%) for non-reminders. After adjusting on all other covariates, we found that patients to whom a reminder was sent via email (aOR: 1.45; CI: 1.08, 1.94), SMS (aOR: 2.95; CI: 2.41, 3.60), and both SMS and email (aOR: 2.86, CI: 1.37, 5.96) were more likely to show up on their appointment day compared to those who did not receive any reminder. Other socio-demographic factors such as being 50 years and older (aOR: 1.31; CI: 1.10, 1.56) compared to under 30 years, living as couple (aOR: 1.23; CI: 1.10, 1.37), and not having children (aOR: 1.21; CI: 1.07, 1.37) were significantly associated with appointment attendance.ConclusionsOur study suggests that patient reminder systems may be used to reduce non-attendance in Haiti, even in a context of socio-political crisis.

Preoperative Anesthesia Virtual Video Consultations in a Preadmission Clinic: Quality Improvement Study.

The preadmission clinic (PAC) is crucial in perioperative care, offering evaluations, education, and patient optimization before surgical procedures. During the COVID-19 pandemic, the PAC adapted by implementing telephone visits due to a lack of infrastructure for video consultations. While the pandemic significantly increased the use of virtual care, including video appointments as an alternative to in-person consultations, our PAC had not used video consultations for preoperative assessments. This study aimed to develop, implement, and integrate preoperative video consultations into the PAC workflow. A prospective quality improvement project was undertaken using the Plan-Do-Study-Act (PDSA) methodology. The project focused on developing, implementing, and integrating virtual video consultations at London Health Sciences Centre and St. Joseph Health Care (London, Ontario, Canada) in the PAC. Data were systematically collected to monitor the number of patients undergoing video consultations, address patient flow concerns, and increase the percentage of video consultations. Communication between the PAC, surgeon offices, and patients was analyzed for continuous improvement. Technological challenges were addressed, and procedures were streamlined to facilitate video calls on appointment days. The PAC team, which includes professionals from medicine, anesthesia, nursing, pharmacy, occupational therapy, and physiotherapy, offers preoperative evaluation and education to surgical patients, conducting approximately 8000 consultations annually across 3 hospital locations. Following the initial PDSA cycles, the interventions consistently improved the video consultation utilization rate to 17%, indicating positive progress. With the onset of PDSA cycle 3, there was a notable surge to a 29% utilization rate in the early phase. This upward trend continued, culminating in a 38% utilization rate of virtual video consultations in the later stages of the cycle. This heightened level was consistently maintained throughout 2023, highlighting the sustained success of our interventions. The quality improvement process significantly enhanced the institution's preoperative video consultation workflow. By understanding the complexities within the PAC, strategic interventions were made to integrate video consultations without compromising efficiency, morale, or safety. This project highlights the potential for transformative improvements in health care delivery through the thoughtful integration of virtual care technologies.

Access to clinical genetic services: An evaluation of patient referral characteristics and identifying barriers in Michigan.

The utilization of genetics in medical care has enhanced the utility of precision medicine and hence increased the need for clinical genetic services. These services have reduced the costs and expanded the availability of genetic testing, but their use is limited in certain populations. This study explores the access to clinical genetic services for Michigan patients referred to a genetics clinic on the western side of the state. Factors included the travel distance (miles), wait time for appointment (days from the referral date to the date of first appointment), population demographics, and cultural characteristics. A retrospective record review of all aged patients (n = 568) referred to a genetics clinic in 2018 demonstrated that all patients were insured (100%), of which majority were white-non-Hispanic (90.7%), more than half were < 10 years of age at referral (53.3%), and most of them kept their first appointment (93.5%). Our analysis showed that the wait time was associated with referral non-compliance, p < 0.01. Adjusting for all variables, for each additional day in wait time, patients had 1% increased risk of not seeking clinical genetic services (OR = 1.01, 90% CI [1.01, 1.02]). Policies to encourage genetic service utilization and improve equitable access to precision health are needed. An opportunity exists for strategies that broaden and add diverse populations to those receiving genetic services.

Outpatient Consultation of Diabetes and Cardiovascular Diseases Patients in Abuja Public Hospitals Based on Selected Indicators

AIM. Diabetes and cardiovascular diseases are among the reasons for most outpatient consultations. The study aimed to evaluate the reported experiences of patients being managed for diabetes and cardiovascular diseases in the outpatient clinics of Abuja public hospitals. METHOD. A prospective cross-sectional study of 787 systematically sampled patients receiving care in five public hospitals in Abuja was conducted. A structured questionnaire was used to collect data on the number of yearly consultations, problems encountered in accessing trained health personnel, time spent on hospital appointments, major treatment challenges, and ways to improve their experience on hospital visits. Consultation experience was defined as good or poor. Patients who consulted at least four times in a year, reported no problems in accessing trained health personnel, and had no treatment challenges were regarded as having a good consultation experience. Frequency, percentage, mean, and standard deviation were used to summarize the data. Logistic regression was used to predict and classify the binary outcomes. A p-value ≤ 0.05 was considered significant. RESULTS. More of the patients (66.2%) had up to four consultations in a year. Long waiting time (56.1%) was the common problem encountered when accessing trained medical personnel. The major treatment challenge was hospital waiting time (49.4%). The mean time spent in the hospital on appointment days was 5.04±1.80. Approximately 40% of the patients suggested proper scheduling of hospital appointments as the major way to improve treatment experiences. Poor consultation was recorded by 96.6% of the patients. Logistic regression showed that a higher educational level (OR = 0.031, 95% CI [0.008-0.119], _P=_0.001) was associated with reporting poor management. CONCLUSION. The average number of yearly consultations was below the minimum standard, and patients spent long hours on consultation days before meeting with healthcare personnel. Most patients were dissatisfied with the services received and rated them poor.

Abortion Provision and Delays to Care in a Clinic Network in Washington State After Dobbs

The Supreme Court decision Dobbs v Jackson Women's Health Organization (Dobbs) overturned federal protections to abortion care and altered the reproductive health care landscape. Thus far, aggregated state-level data reveal increases in the number of abortions in states where abortion is still legal, but there is limited information on delays to care and changes in the characteristics of people accessing abortion in these states after Dobbs. To examine changes in abortion provision and delays to care after Dobbs. Retrospective cohort study of all abortions performed at an independent, high-volume reproductive health care clinic network in Washington state from January 1, 2017, to July 31, 2023. Using an interrupted time series, the study assessed changes in abortion care after Dobbs. Abortion care obtained after (June 24, 2022, to July 31, 2023) vs before (January 1, 2017, to June 23, 2022) Dobbs. Primary outcomes included weekly number of abortions and out-of-state patients and weekly average of gestational duration (days) and time to appointment (days). Among the 18 379 abortions during the study period, most were procedural (13 192 abortions [72%]) and funded by public insurance (11 412 abortions [62%]). The mean (SD) age of individuals receiving abortion care was 28.5 (6.44) years. Following Dobbs, the number of procedural abortions per week increased by 6.35 (95% CI, 2.83-9.86), but then trended back toward pre-Dobbs levels. The number of out-of-state patients per week increased by 2 (95% CI, 1.1-3.6) and trends remained stable. The average gestational duration per week increased by 6.9 (95% CI, 3.6-10.2) days following Dobbs, primarily due to increased gestations of procedural abortions. The average gestational duration among out-of-state patients did not change following Dobbs, but it did increase by 6 days for in-state patients (5.9; 95% CI, 3.2-8.6 days). There were no significant changes in time to appointment. These findings provide a detailed picture of changes in abortion provision and delays to care after Dobbs in a state bordering a total ban state. In this study, more people traveled from out of state to receive care and in-state patients sought care a week later in gestation. These findings can inform interventions and policies to improve access for all seeking abortion care.

Assessment of Outpatient Management of Diabetes and Cardiovascular Diseases in Abuja Public Hospitals

AIM. Diabetes and cardiovascular diseases are among the reasons for most outpatient consultations. The study aimed to evaluate the reported experiences of patients being managed for diabetes and cardiovascular diseases in the outpatient clinics of Abuja public hospitals. METHOD. A prospective cross-sectional study of 787 systematically sampled patients receiving care in five public hospitals in Abuja was conducted. A structured questionnaire was used to collect data on the number of yearly consultations, problems encountered in accessing trained health personnel, time spent on hospital appointments, major treatment challenges, and ways to improve their experience on hospital visits. Management experience was defined as good or poor. Patients who consulted at least four times in a year, reported no problems in accessing trained health personnel, and had no treatment challenges were regarded as having a good management experience. Frequency, percentage, mean, and standard deviation were used to summarize the data. Logistic regression was used to predict and classify the binary outcomes. A p-value ≤ 0.05 was considered significant. RESULTS. More of the patients (66.2%) had up to four consultations in a year. Long waiting time (56.1%) was the common problem encountered when accessing trained medical personnel. The major treatment challenge was hospital waiting time (49.4%). The mean time spent in the hospital on appointment days was 5.04±1.80. Approximately 40% of the patients suggested proper scheduling of hospital appointments as the major way to improve treatment experiences. Poor management was recorded by 96.6% of the patients. Logistic regression showed that a higher educational level (OR = 0.031, 95% CI [0.008-0.119], _P=_0.001) was associated with reporting poor management. CONCLUSION. The average number of yearly consultations was below the minimum standard, and patients spent long hours on consultation days before meeting with healthcare personnel. Most patients were dissatisfied with the services received and rated them poor.

Behavioural interventions to increase adherence to palivizumab prophylaxis in children with CHD.

Adherence to palivizumab prophylaxis programmes is crucial to protect infants with CHD against respiratory syncytial virus infections. We analysed the effectiveness of two nudge interventions in increasing adherence. Our study included 229 infants, and their caregivers, from five centers in Turkey in the 2020-2021 respiratory syncytial virus season. We randomly allocated caregivers to a control and two intervention groups. Caregivers in all groups were informed about the prophylaxis programme and provided a schedule. Additionally, caregivers in Intervention 1 were called two days before appointments (default bias) and were asked to plan the appointment day (implementation intention), whereas caregivers in Intervention 2 received biweekly text messages informing them about the programme's benefits (availability bias) and current adherence rate (social norm). Caregivers in Intervention 1 had a significantly higher adherence rate than Control (97.3% versus 90.9%) (p = 0.014). Both interventions had a significant effect on participants in their first prophylaxis season (p = 0.031, p = 0.037). Families where the father was employed had a 14.2% higher adherence rate (p = 0.001). Every additional child was associated with a 2.2% decrease in adherence rate (p = 0.02). In control, ICU admission history was associated with an 18.8% lower adherence rate (p = 0.0001), but this association disappeared in intervention groups. This is the first prospective interventional study which, in the context of palivizumab prophylaxis, analyses the effectiveness of nudge interventions based on established cognitive biases by comparing randomly generated intervention and control groups. We found that default bias and implementation intention have significant effects on adherence.Clinical trial, in the name and number "Adherence of palivizumab prophylaxis, NCT05778240" registered retrospectively. https://clinicaltrials.gov/ct2/show/NCT05778240.

Creating a Palliative Care Clinic for Patients with Cancer Pain and Substance Use Disorder

BackgroundOpioids are a first-line treatment for severe cancer pain. However, clinicians may be reluctant to prescribe opioids for patients with concurrent substance use disorders (SUD) or clinical concerns about non-prescribed substance use. MeasuresPatient volume, 60-day retention rate, and use of sublingual buprenorphine to treat opioid use disorder. InterventionWe created the Palliative Harm Reduction and Resiliency Clinic, a palliative care clinic founded on harm reduction principles and including formal collaboration with addiction psychiatry. OutcomesDuring the first 18 months, patient volume increased steadily; 70% of patients had at least one subsequent visit within 60 days of the initial appointment; and buprenorphine was prescribed for 55% of patients with opioid use disorder. Conclusions/Lessons LearnedThe formal collaboration with addiction psychiatry and the integration of harm reduction principles and practices into ambulatory palliative care improved our ability to provide treatment to a previously underserved patient population with high symptom burden.

Appointment Requests from Multiple Channels: Characterizing Optimal Set of Appointment Days to Offer with Patient Preferences

We consider the appointment scheduling for a physician in a healthcare facility. Patients, of two types differentiated by their revenues and day preferences, contact the facility through either a call center to be scheduled immediately or a website to be scheduled the following morning. The facility aims to maximize the long-run average revenue, while ensuring that a certain service level is satisfied for patients generating lower revenue. The facility has two decisions: offering a set of appointment days and choosing the patient type to prioritize while contacting the website patients. Model 1 is a periodic Markov Decision Process (MDP) model without the service-level constraint. We establish certain structural properties of Model 1, while providing sufficient conditions for the existence of a preferred patient type and for the nonoptimality of the commonly used offer-all policy. We also demonstrate the importance of patient preference in determining the preferred type. Model 2 is the constrained MDP model that accommodates the service-level constraint and has an optimal randomized policy with a special structure. This allows developing an efficient method to identify a well-performing policy. We illustrate the performance of this policy through numerical experiments, for systems with and without no-shows. Supplemental Material: The online appendix is available at https://doi.org/10.1287/stsy.2022.0029 .

No-Show Rates in an Academic Otolaryngology Practice Before and During the COVID-19 Pandemic.

Our objectives were to determine the no-show and nonattendance rate for an outpatient academic otolaryngology practice, to identify patient and systemic factors associated with nonattendance, and to evaluate the impact that the COVID-19 pandemic had on the rate of nonattendance. This is a retrospective review of the Epic practice management and billing reports from all scheduled outpatient visits at a multi-physician, academic, general, and sub-specialty otolaryngology practice from January 2019 to December 2021. Over three years, 121,347 clinic visits were scheduled in the otolaryngology practice. The overall nonattendance rate was 18.3%. A statistically significant increase in nonattendance was noted during the COVID-19 pandemic (16.8% vs. 19.8%, p < 0.001). The rate of nonattendance in patients of younger age (under 18 years) (p <0.001), female gender (p=0.03), afternoon appointments (p=0.04), and extended time between the day of scheduling and the day of appointment (p <0.001) increased. Head and neck clinics were found to have the lowest nonattendance rates, while pediatric otolaryngology clinics had the highest (12.6% vs. 21.3%). On multivariate regression, younger age (p < 0.001), female gender (p=0.01), afternoon appointments (p< 0.001), and online self-scheduling (p< 0.001) were significantly associated with nonattendance. Both patient and appointment-related factors were found to impact rates of nonattendance in this academic otolaryngology practice. In this study, young age, female gender, afternoon appointments, and online self-scheduling were associated with increased nonattendance. In addition, the COVID-19 pandemic significantly impacted no-show rates across all otolaryngologic subspecialties.

An Orthopaedic perspective on developing a Patient Experience Survey tool

Introduction: Our program’s aim is to integrate patients' values and perceptions of quality care into clinical decision-making and integrated orthopaedic care models that are reflective of the community/population that is served. Our institution currently has limited patient experience data or standardized tools that would allow us to comprehensively understand patient perspective across our orthopaedic populations. To that end, we designed a survey to understand patients’ experiences and any gaps that would require actionable change in real-time.&#x0D; Objectives and Methodology: The goal was to develop a survey tool that can meaningfully capture patient needs and preferences that impact their experiences and help identify any gaps or areas of opportunity to address. An environmental scan was completed which identified two validated patient experience surveys used to inform our survey development: CIHI’s CPES-IC (Canadian Institue for Health Information Canadian Patient Experience Survey - Inpatient Care) and OHA (Ontario Hospital Association) Outpatient Experience Survey. The survey was tested across a multidisciplinary team via feedback surveys and focus groups: 6 Patient Partners, 1 Clinical Manager, 3 Advanced Practice Practitioners, 3 Orthopaedic Surgeons, 4 Researchers, and 2 Administrators. Findings were collated and used to iterate the survey content until consensus was reached on a final patient experience survey. &#x0D; Highlights or Results or Key Findings: The focus of the survey is on understanding the patient’s Outpatient experience with their care team in orthopaedic clinics from referral to assessment. The survey was designed to cover multiple orthopaedic populations including patients with Hip and Knee, Foot and Ankle, Shoulder, Elbow and Spine issues. It focuses on two key components of the patient journey: 1) Pre-appointment and 2) Post-appointment. The pre-appointment pathway was deemed to be important as patient experience is often captured once care is delivered and it was important to understand how patients perceive their pre-appointment experience defined as the time from referral through day of appointment up to the time patients are seen (arrival at hospital, checking in to clinic). Specifically, the pre-appointment survey has up to 42 questions that aim to capture the patients’ perspectives on the clinic’s communication practices, wait time to be contacted, wait time for an appointment, how prepared patients felt for their appointment, how they felt about access to the clinic, their experiences with care transitions, their thoughts on transportation and any education that they received, and their overall experience. The post-appointment survey has up to 41 questions focused on understanding the patients’ perspectives on care transitions, the clinic space; wait time to see the practitioner, expectations, engagement in decision making, communication practices, education they received, and any other factors impacting their experience (e.g. confidentiality, empathy, trust, dignity). &#x0D; Conclusion and Next Steps: The survey, reviewed with our patient partners and multidisciplinary team, was found to be comprehensive and have good face validity. The survey will be implemented and the data will be analyzed to understand themes around areas of success and areas of improvement to advance our integrated models of care in order to provide high quality patient-centered care.

Use of an Advance Chart Preparation Process Improves Overall Care in Pediatric Patients with Sickle Cell Disease

Background: Clinics have mostly used pre-clinic chart reviews to increase efficiency of patient appointments and typically only include the provider the day the patient is seen in the clinic. Additionally, these pre-clinic chart reviews tend to focus only on the biomedical needs of the patients and do not often account for the patients' needs relating to social determinants of health (SDoH). Objective: To improve clinical care consistent with national guidelines and enhance comprehensive care coordination for patients with sickle cell disease (SCD) through an advanced chart preparation process incorporating multi-disciplinary team members (Community Health Worker, Research Coordinators, Nurses, and Medical Providers). Methods: Scheduled chart-prep meetings (CPMs) are held approximately 2 weeks before SCD clinic, and are routinely attended by the SCD team spanning multiple disciplines: community health worker (CHW), research coordinators (RC), nurses, and providers. If additional personnel, such as palliative care, counseling, exercise physiology, dietitian, etc., are needed for CPMs, they are invited in advance to the meeting. In preparation for the CPM, a nurse care coordinator conducts a chart review of each scheduled patient to complete a standardized guided chart prep sheet (Fig. 1). During CPMs, the chart prep sheet is used to discuss each patient to ensure all standard of care guidelines are met along with quality improvement objectives. The guided sheet also addresses personalized medical needs for the individual patient, social needs, school/career plans, transition, subspecialty referrals, and screening for eligibility to participate in open QI and research projects. The CPMs assure optimal completion of the following pre-appointment activities: (1) order placement, (2) acquiring external patient data relevant to the upcoming visit, (3) coordinating other same-day testing/appointments, and (4) accommodating social needs (i.e., transportation). After closing any care gaps, the CPM sheet is incorporated into the clinic appointment flow for brief provider review immediately prior to seeing the patient and to assure completion of all needed assessments. Results: CPMs have improved a variety of patient care metrics, making patient appointments more efficient, comprehensive, and patient-focused, and improving pre and post-appointment coordination of care. The advanced chart preparation process increases efficiency for patients, families, and providers. One example has been the increase of annual TCD completion rates from 50% to 93%, largely accomplished by coordinating TCD and clinic appointments, especially for patients living hours from the clinic. Combining other services and appointments on the same appointment day minimizes transportation needs and maximizes completed referral appointments. Incorporating a patient immunization database into CPMs has improved immunization completion rates significantly, more than doubling the rates for some (Men A from 11% to 93%, Men B from 15% to 83%) (Fig. 2). Overall, the CPMs: 1) maximize quality time with patients, 2) assure discussion of non-medical (interpersonal, school, etc.) issues, 3) encourage patient and family medical education opportunities, 4) emphasize attention to each patient's individual SDoH needs, 5) increase successful care coordination, 6) enhance collaboration among members of the SCD care team, 7) provide ongoing focus on QI initiatives, and 8) facilitate patient enrollment in open clinical studies and research trials. Conclusions: Our multidisciplinary SCD care team found that CPMs result in more efficient, effective, and comprehensive patient- and family-centered care while promoting care collaboration by team members. They promoted adherence to guidelines, as evidenced by significant increases in TCD (up 43%) and immunization rates (average improvement 36%, with biggest improvements 82% and 68%, shown above). In addition, the time put into appointment preparation has allowed us to use more clinic time to develop trusting relationships with the patients and families we serve. Furthermore, this process has facilitated patient participation in QI efforts, new databases, and clinical trials. Such chart prep meetings are easily adaptable to a variety of clinical care teams and health delivery settings.

Factors Influencing Adherence to Antiretroviral Therapy among HIVpositive Youth Patients Attending ART Clinic in Kiryandongo General Hospital Kiryandongo District

This research aimed to assess the factors influencing adherence to antiretroviral therapy (ART) among HIV-positive youth patients attending the ART Clinic in Kiryandongo General Hospital, Kiryandongo District. The study utilized a descriptive cross-sectional research design, with a sample of 355 respondents between the ages of 10 and 25 who were receiving antiretroviral treatment. The study found a low level of adherence to antiretroviral treatment (33%), significantly lower than the national target of 90%. Adherence was influenced by various individual, drug-related, and healthcare factors. Individual factors included gender, age, marital status, education, place of residence, family size, and religion. Drug-related factors included having all the required drugs, challenges with the drugs, the frequency of taking ARV pills, challenges during medication intake, and accessibility to ARV drugs. Health-related factors encompassed routine education and counseling, sources of information, proximity to healthcare facilities, distance from home to the facility, availability of ARVs on appointment days, availability of healthcare workers, frequency of ARV refill visits, and waiting time during appointments. The low adherence was attributed to missing doses due to stigma, forgetfulness, drug stockouts, lack of routine education about ART, long distances to healthcare facilities, inadequate information, and extended waiting times. Keywords: HIV, Antiretroviral therapy, Adherence, Youths, Stigma

Modification of resting metabolism, body composition, and muscle strength after resolution of coronavirus disease 2019

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes changes that can influence human metabolism and modify the distribution of body compartments. We aimed to describe the clinical findings of changes in resting metabolism, muscle strength, and body composition in nonhospitalized patients after being diagnosed with coronavirus disease 2019 (COVID-19). Physically active patients were evaluated at a nutrition clinic, and indirect calorimetry (IC) and body composition analysis using portable ultrasound were performed. After a routine appointment, all patients were instructed to inform the staff if they tested positive for SARS-CoV-2 infection. Our sample included individuals diagnosed with COVID-19, confirmed by real-time reverse transcription polymerase chain reaction (RT-PCR), within 7 days of the routine appointment. After an average incubation period of 14-21 days, in which there was no proven transmission of disease by RT-PCR, all of the patients were re-evaluated. A total of 38 volunteers (63.2% female) completed the study and were included in the analysis. The mean age of the participants was 37.3±8.8 years. The comparison between pre- and post-COVID-19 stratified by sex demonstrated significant reduction in the RMR and RMR adjusted for weight (p<0.0001) for both groups. Regarding body composition, there was a significant increase observed in fat mass in men (p<0.002) and women (p<0.01), and a significant reduction observed in fat-free mass (men: p<0.002; women: p<0.001) and skeletal muscle mass (men: p=0.003; women: p<0.0001). There was a significant difference between the change in the RMR measured by IC (p<0.0001) and that calculated by the predictive equation of Cunningham (1980) (p<0.0001), whereas the Harris and Benedict (1918) and Mifflin (1990) equations exhibited no difference. However, the mean difference in RMR between the post- and pre-COVID-19 calculated by the Cunningham equation was-40.4kcal/day (95% confidence interval [CI]:-56.38 to-24.45), whereas the mean difference measured by IC was-362.3kcal/day (95% CI:-452.7 to-271.9). This study describes the trends in the RMR, and body composition in individuals with COVID-19 who were not hospitalized from the pre-COVID-19 period to the post-COVID-19 period. A significant reduction in resting energy expenditure, and loss of fat-free mass and muscle mass in the post-COVID-19 period were observed in both men and women.

Evaluation of a remote monitoring service for patients with COVID-19 discharged from University College London Hospital.

In May 2020 a virtual ward for COVID-19 patients seen at University College London Hospital (UCLH) was established. The aim of this study was to see if specific factors can be used to predict the risk of deterioration and need for Emergency Department (ED) reattendance or admission. We performed a service evaluation of the COVID-19 virtual ward service at UCLH between 24/10/2020 and 12/2/2021. 649 patients were included with data collected on vital signs, basic measurements, and blood tests from their initial ED attendance, allowing calculation of ISARIC-4C mortality scores. Outcomes of interest were ED reattendance, facilitation of this by virtual ward physician, level of care if admitted, and death within 28 days of the first COVID-19 virtual ward appointment. Analysis was performed using Mann-Whitney U tests. Reattendance rate to ED was 17.3% (112/649) of which 8% (51/649) were admitted. Half of ED reattendances were facilitated by the virtual ward service. Overall mortality was 0.92%. Patients who reattended ED, facilitated by the virtual ward service, had a higher mean CRP (53.63 vs 41.67 mg/L), presented to ED initially later in their COVID-19 illness (8 vs 6.5 days) and had a higher admission rate (61 vs 39%). The mean ISARIC-4C score was higher in the reattendance group compared to the non-reattendance group (3.87 vs 3.48, difference of 0.179, p = 0.003). The mean ISARIC-4C score was higher in the admission group than the non-reattendance group (5.56 vs 3.48, difference of 0.115, p = 0.003). Identification of patient risk factors for reattendance following a diagnosis of COVID-19 in ED can be used to design a service to safely manage patients remotely. We found that the ISARIC -4C mortality score was associated with risk of hospital admission and could be used to identify those requiring more active remote follow up.

Effect of a National VHA Medical Scribe Pilot on Provider Productivity, Wait Times, and Patient Satisfaction in Cardiology and Orthopedics

BackgroundSection 507 of the VA MISSION Act of 2018 mandated a 2-year pilot study of medical scribes in the Veterans Health Administration (VHA), with 12 VA Medical Centers randomly selected to receive scribes in their emergency departments or high wait time specialty clinics (cardiology and orthopedics). The pilot began on June 30, 2020, and ended on July 1, 2022.ObjectiveOur objective was to evaluate the impact of medical scribes on provider productivity, wait times, and patient satisfaction in cardiology and orthopedics, as mandated by the MISSION Act.DesignCluster randomized trial, with intent-to-treat analysis using difference-in-differences regression.PatientsVeterans using 18 included VA Medical Centers (12 intervention and 6 comparison sites).InterventionRandomization into MISSION 507 medical scribe pilot.Main MeasuresProvider productivity, wait times, and patient satisfaction per clinic-pay period.Key ResultsRandomization into the scribe pilot was associated with increases of 25.2 relative value units (RVUs) per full-time equivalent (FTE) (p < 0.001) and 8.5 visits per FTE (p = 0.002) in cardiology and increases of 17.3 RVUs per FTE (p = 0.001) and 12.5 visits per FTE (p = 0.001) in orthopedics. We found that the scribe pilot was associated with a decrease of 8.5 days in request to appointment day wait times (p < 0.001) in orthopedics, driven by a 5.7-day decrease in appointment made to appointment day wait times (p < 0.001), and observed no change in wait times in cardiology. We also observed no declines in patient satisfaction with randomization into the scribe pilot.ConclusionsGiven the potential improvements in productivity and wait times with no change in patient satisfaction, our results suggest that scribes may be a useful tool to improve access to VHA care. However, participation in the pilot by sites and providers was voluntary, which could have implications for scalability and what effects could be expected if scribes were introduced to the care process without buy-in. Cost was not considered in this analysis but is an important factor for future implementation.Trial RegistrationClinicalTrials.gov Identifier: NCT04154462.

SUCESS OF EXCLUSIVE BREASTFEEDING AT THE 30TH DAY OF CORRECTED AGE PRETERM INFANTS UNDER KANGOROO CARE

&#x0D; Objective: Breastfeeding is associated with multiple benefits for preterm infants. Kangaroo care is a strategy geared towards making the aforementioned practice successful. This study examined the rate of exclusive breastfeeding (EBF) at the 30th day of corrected gestational age (CGA) appointment and the maternal and neonatal factors associated with this outcome in preterm infants assisted by kangaroo care. Methods: A cross-sectional study was conducted on very low birth weight (below 1500g) newborns and/or those with gestational age below 33 weeks, born from January 2019 to February 2020 and monitored in the outpatient follow-up. For EBF yes (G1) or no (G2), bivariate and multivariate analyses were performed. Results: 87 (100%) patients attended the 30th day of CGA appointment, 43 (49.4%) on EBF, 30 (34.5%) on breastfeeding and 14 (16.1%) on formula only. The median gestational age and birth weight were 31 weeks (29-32) and 1370g (1190-1670), respectively, and 51 (58.6%) patients were female. There was no difference in the bivariate analysis of maternal age, preeclampsia, route of delivery, antenatal corticosteroid use, birth weight, neonatal morbidities, length of hospitalization, chronological age, and anthropometry at the 30th day of CGA between the G1 and G2 groups. In multivariate analysis, gestational age above 30 weeks (RC3.11/p=0.034) and breastfeeding duration above 30 minutes (RC3.77/p=0.013) were determinants of EBF. Conclusion: Successful breastfeeding rates were observed in 2020 in this at-risk population, especially compared to previous years' results from this and other institutions. The newborn's longer breastfeeding time, one of the strategies of kangaroo care, was shown to be a protective factor for the maintenance of EBF in this outpatient follow-up, and special attention should be given to those born under 30 weeks, who showed a higher risk of weaning.

Telemedicine for Patients With Systemic Lupus Erythematosus in a Publicly Funded Hospital System: Retrospective Study.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that requires frequent clinic and laboratory visits. However, patients with SLE, particularly those who are underresourced, have unacceptably high rates of no-shows. This study aims to determine no-show rates associated with telemedicine visits during the COVID-19 pandemic in comparison to no-show rates associated with contemporaneous and historic in-person visits. We performed a retrospective cohort study in a publicly funded county hospital system in Houston, Texas. We identified a cohort of established patients with SLE by the International Classification of Diseases codes that were independently confirmed as SLE by a review of medical records. We identified patients who were seen from March to December in 2018, 2019, and 2020 (to reflect the height of the COVID-19 pandemic and account for seasonal changes in disease activity). Our primary outcome was the percentage of no-shows for rheumatology clinic appointments. Our secondary outcome was laboratory use adherence, which was defined as lupus-specific blood and urine studies conducted within 30 days of the scheduled appointment. Covariates included age, sex, race, ethnicity, and SLE-related prescription drugs. We included 156 patients with SLE in our analysis. Most were female (n=141, 90.4%), were Hispanic (n=75, 49.3%), and had a median age of 43 (range 19-80) years. In 2020, the no-show rate for telemedicine was 5.5% (10/182) compared to a no-show rate of 16.2% (31/191) for in-person visits (P=.002). After multivariable adjustment for covariates, the odds of no-show were lower for telemedicine visits (odds ratio 0.39, 95% CI 0.20-0.77). There were no differences in adherence to laboratory testing. Telemedicine visits had decreased odds of no-shows without difference in laboratory testing adherence after adjustment for covariates. More research is needed to determine the clinical impact of telemedicine on patients with SLE.

January 30, 1933, in the Nazi Historical Imaginary

AbstractFrom 1934 until 1945, the Nazi regime celebrated the anniversary of January 30, 1933, the day of Hitler's appointment as Reich Chancellor. This article, based on unpublished and published documents from central and local Nazi and state institutions, asks how the Nazis choreographed these celebrations at home and abroad and how they fit into broader Nazi conceptualizations of history. Stage-managed celebrations etched January 30 into the historical consciousness of Germans as beginning of the Third Reich and were a crucial step toward the realization of the Volksgemeinschaft (national community), although the Nazi seizure of power was a process and cannot be pinpointed to a single date. Ambivalence characterized the festivities, reflecting the fact that the Nazis saw their coming to power as both revolutionary and restorative of the natural flow of German history. In the Nazi imaginary, this day was a conjuncture in history, separating the Nazi struggle for power from their triumphant mission to “make Germany great again” and create a racial utopia.

Medicaid coverage and access to obstetrics and gynecology subspecialists: findings from a national mystery caller study in the United States

Previous research suggests that access to healthcare may influence the diagnosis and treatment of obstetrical and gynecologic pathologies. Audit studies, a single-blinded and patient-centered design, have been employed to measure access to care for health services. To date, no study has assessed the dimensions of access to obstetrics and gynecologic subspecialty care based on insurance type (Medicaid vs commercial). This study aimed to evaluate the mean appointment wait time for a new patient visit to female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal-fetal medicine, and reproductive endocrinology and infertility when presenting with Medicaid vs commercial insurance. Each subspecialty medical society has a patient-facing physician directory of physicians across the United States. Of note, 800 unique physicians were randomly selected from the directories (200 per subspecialty). Of the 800 physicians, each physician was called twice. The caller presented with Medicaid or, in a separate call, with Blue Cross Blue Shield. The order in which the calls were placed was randomized. The caller asked for the soonest appointment available for respective medical conditions based on subspecialty: stress urinary incontinence, new-onset pelvic mass, preconceptual counseling after an autologous kidney transplant, and primary infertility. From 800 physicians initially contacted, 477 responded to at least 1 call in 49 states plus the District of Columbia. The mean appointment wait time was 20.3 business days (standard deviation, ±18.6). A significant difference was found in new patient appointment wait times by type of insurance, with 44% longer wait time for Medicaid (ratio, 1.44; 95% confidence interval, 1.34-1.54; P<.001). When the interaction between insurance type and subspecialty was added to the model, it was also highly significant (P<.01). More specifically, Medicaid patients in female pelvic medicine and reconstructive surgery had a longer wait time than commercially insured patients. Patients seeking care in maternal-fetal medicine had the least difference, but Medicaid-insured patient wait times were still longer than commercial-insured patient wait times. Typically, a patient can expect to wait 20.3 days for a new patient appointment with a board-certified obstetrics and gynecology subspecialist. Callers presenting with Medicaid insurance experienced significantly longer new patient appointment wait times than callers with commercial insurance.