Assignment Of Patients Research Articles

Assessing and attending to psychosocial concerns in genetic counseling: Proposing the BATHE method.

The process of identifying and responding to patients' social, emotional, and psychological concerns is a required skill for training and practicing genetic counselors. Patients' health outcomes are improved when genetic counselors attend to these "psychosocial" concerns. Still, the process of eliciting, assessing, and attending to patients' psychosocial concerns in the genetic counseling setting is not well defined in the literature nor is it performed consistently. Tools that do exist are often questionnaire-based, designed for research use, or occur outside of a genetic counseling appointment. Here we describe the complexities of defining "psychosocial assessment" in genetic counseling, its impact on patient outcomes, and summarize existing tools for psychosocial assessment. We identify a need for evidenced-based, verbally-administered psychosocial assessment tools in genetic counseling and explore the value of adapting an existing tool from primary care (the BATHE method) to genetic counseling. The BATHE method is a semi-structured psychosocial assessment tool that can be performed quickly within a patient appointment to gather context, emotional impact, the patient's primary concern, and coping strategies. Through our professional experiences we believe it is a beneficial psychosocial assessment tool as perceived by both patients and genetic counselors. Further work is needed to determine if the BATHE method could fill a gap in how genetic counselors conduct a psychosocial assessment.

Effect of the National Enhanced Service for weight management on the content of annual review consultations for patients living with obesity and hypertension and/or diabetes.

Guidelines specify that clinicians should support patients living with obesity by referring to weight management programmes (WMPs), but clinicians do so infrequently. To provide additional support to patients living with obesity and weight-related conditions, the UK government instated the National Enhanced Service (NES) for weight management in England, including a reimbursement to general practices for referring eligible patients to WMPs. To assess the impact of the NES on conversations regarding weight and relevant behavioural risk factors in primary care consultations we recruited 11 medical practices in England where the NES was operating and six comparator practices from Scotland and Wales where the NES was not implemented. Clinicians audio-recorded annual review appointments of patients living with obesity and hypertension and/or diabetes. The content of these consultations was synthesised using quantitative content analysis. Consultations with 92 patients were analysed: 58 in England and 34 in Scotland and Wales. No difference was found between the NES sites (England) and non-NES sites (Scotland and Wales) in the proportion of referrals made to WMPs. Clinicians in England weighed patients and took other body measurements more often, mentioned body mass index more often, and had more detailed discussions about patients' diets, but there was no evidence that they differed in their discussion of WMPs or other modifiable risk factors. We found no strong evidence that the NES affected how clinicians addressed weight management or related behavioural risk factors within annual review consultations for patients living with obesity and hypertension and/or diabetes.

Improving Sickle Cell Patient Appointment Compliance in a Hospital-Based Pediatric Ophthalmology Clinic

This quality improvement initiative aimed to reduce the no-show rate at a hospital-based tertiary sickle cell ophthalmology clinic. Missed appointments place a significant burden on the healthcare system, resulting in prolonged waiting times and underutilized clinical resources that impact the quality of care provided. Individuals with sickle cell disease commonly require multiple appointments to address the myriads of comorbidities associated with their disease. Nevertheless, the sickle cell ophthalmology clinic experienced an alarmingly high no-show rate of 49% from June to September of 2021 despite offering same-day appointments with the hematology clinic. To address this issue, we conducted a study in which we compared the baseline no-show rate with the rate after relocating both clinics to the same floor, aiming to overcome patient-related barriers. Following 3.5 months of the clinics sharing the same floor, the no-show rate decreased to 39%, reflecting a 10% improvement from the baseline rate. In summary, co-locating two related clinics can alleviate patient burdens, foster communication between multidisciplinary specialties, and contribute to an overall improvement in the quality of care and treatment provided.

Missing appointments in Parkinson´s Disease: a longitudinal study on the pattern of attendance and its effects on motor and non-motor symptoms, quality of life and disability progression

Background and PurposeParkinson's Disease (PD) requires regular therapeutic adjustments and ongoing outpatient clinic follow-up. Nevertheless, the impact of appointment non-attendance on PD patients concerning the different symptomatic dimensions of the condition remains uncertain. We compared the level of attendance of PD and Essential Tremor (ET) patients and assessed the value of attendance variables as predictors of progression in cognition, motor dysfunction, affect, disability and health-related quality of life in PD. MethodsThe number of attended, no-shows and cancelled appointments of PD and ET patients were collected over 4 years. PD patients were assessed at baseline and 4 years later with the Non-Motor Symptoms Scale (NMSS), cognition (MoCA), disability (Schwab and England [S&E]), motor dysfunction (UPDRS-III), health-related quality of life measured with EQ-5D and hospital anxiety and depression scale (HADS). Linear regression (univariate) was used to test the correlation between the number of appointments (predictors) and absolute change in the NMSS, MoCA, S&E, UPDRS-III, EQ-5D and HADS. Results62 PD and 35 ET patients were assessed. PD patients attended more appointments (8,08 ± 3,13 vs 5,43 ± 2,09) and had a similar number of no-shows (0,39 ± 0,66 vs 0,46 ± 0,70) and cancelled (0,74 ± 0,88 vs 0,54 ±0,65) appointments than ET patients. In the univariate analysis there was a significant relation between the number of cancelled appointments and change in the S&E score (B=6,375; p=0,022). ConclusionOur findings suggest the number of cancelled appointments, but not no-shows, could be considered a predictor of disability progression in PD.

Gender Based Differences in Electronic Medical Record Utilization in an Academic Ophthalmology Practice

PurposeTo evaluate gender differences in EMR interaction among female and male ophthalmologists at a large tertiary academic center. DesignRetrospective, cross sectional analysis MethodsData from Electronic Medical Record (EMR) system log files and health system administrative data from May 2022 to May 2023 were collected at an academic center. Primary outcomes were differences in time spent interacting with the EMR and In-basket message load between male and female ophthalmologists. Statistical analysis was adjusted for each physicians’ patient panel size, patient panel gender breakdown, and number of appointments. ResultsThere were 30 ophthalmologists, 8 (27%) of whom were female. There was a significantly shorter mean length of employment, defined as years of employment at this institution, for female ophthalmologists (5.62 ± 8.24 vs 15.26 ± 13.34 years, p=0.028). In the 12-month analysis period, there was no significant difference in the total number of patients seen between female and male ophthalmologists. However, female ophthalmologists spent 69.6% more total time in the EMR system (24,553 vs 14,480 minutes/MD, p<0.001), and 70.9% more cumulative time on clinical tasks (18,424 vs 10,887 minutes/MD, p<0.001). Female ophthalmologists spent 114% more time than male counterparts on placing orders, scheduling tasks, and responding to in-basket messages (6484 vs 3024 minutes/MD, p<0.001). Female ophthalmologists also received 750% higher volume of patient notification messages (187 vs 22, p<0.001). ConclusionsIn our cohort, male ophthalmologists’ mean duration of employment was nearly 3 times longer than female ophthalmologists. Despite comparable patient panels and appointment completion rates, female ophthalmologists spent significantly more time in the EMR system and received significantly more in-basket messages and tasks. These findings underscore the need for further studies addressing gender disparities and promoting gender equity in ophthalmology practice settings.

OA07 Upadacitinib exposure during pregnancy in seronegative Rheumatoid arthritis

Abstract Introduction Targeted therapies have become increasingly prevalent in the management of rheumatoid arthritis (RA), with Janus kinase inhibitors (JAK inhibitors) gaining traction in clinical practice. Upadacitinib, a selective JAK1 inhibitor, is widely used for its efficacy in controlling RA. However, preclinical studies have demonstrated teratogenic effects associated with JAK inhibitors, raising concerns about their safety during pregnancy. Given the limited data on human exposure, current guidelines recommend the immediate discontinuation of JAK inhibitors upon pregnancy detection. This case report details an instance of Upadacitinib exposure during pregnancy. Case description A 36-year-old woman was diagnosed with seronegative RA in January 2020. Her medical history is otherwise unremarkable. She has two children, aged four and two, both of whom were born after uneventful pregnancies. She has no history of spontaneous abortions. At the time of her RA diagnosis, the patient was considering pregnancy and was initially started on sulfasalazine. However, due to the development of a rash, her treatment was switched to certolizumab injections. Despite this treatment, she exhibited only a partial response with ongoing disease activity, leading to a change to etanercept in August 2021. When etanercept proved ineffective, adalimumab was considered in January 2022. Unfortunately, her response to adalimumab was limited. Consequently, she was started on Upadacitinib in July 2022. The patient responded well to Upadacitinib, achieving remission with normal inflammatory markers. In April 2024, the patient reported being six weeks pregnant while on Upadacitinib. Upon confirmation of her pregnancy, Upadacitinib was discontinued at approximately four weeks of gestational age. The parents were informed about the potential risks of teratogenicity. After a detailed discussion with the high-risk pregnancy team, who provided reassurance, the patient decided to continue the pregnancy. She was subsequently started on certolizumab. Unfortunately, the patient experienced a miscarriage at 11 weeks of gestation. Discussion Currently, there are no published human studies available in the literature regarding the effects of upadacitinib during pregnancy. It is crucial to encourage adequate contraception for women of childbearing potential and to verify a negative pregnancy status before initiating therapy. Women with reproductive potential should be advised to use effective contraception during upadacitinib therapy and for at least four weeks after discontinuation. If a patient becomes pregnant while on the drug, they should be informed of the potential risks to the foetus. According to the 2019 product information on upadacitinib, animal studies have shown that the drug, when administered at exposures equal to or greater than approximately 1.6 to 15 times the maximum recommended human dose, resulted in dose-related increases in skeletal and cardiovascular malformations, increased post-implantation loss, and decreased foetal body weights. There are no controlled data on upadacitinib use during human pregnancy, and it is unknown whether the drug can cause foetal harm or adversely affect reproductive capacity in humans. Data about pregnancy while on upadacitinib is limited. There are some unpublished data from the clinical trials and it was noted most of the patients had live births without congenital anomaly. Spontaneous abortions, elective terminations and ectopic pregnancies were among the other outcomes noted. Key learning points • Due to issues such as primary or secondary treatment failures, hypersensitivity reactions, and adverse events, patients often require sequential trials of different agents in management of Rheumatoid Arthritis (RA). Janus kinase inhibitors (JAK inhibitors) have shown remarkable efficacy in managing RA over the last decade. Despite their widespread use, there is limited literature on the safety of upadacitinib exposure during pregnancy in humans. Most of the available data come from unexpected pregnancies documented during clinical trials. • Animal studies indicate that upadacitinib can be harmful to a developing foetus. Furthermore, data suggest that women with RA who experience increased disease activity are at a heightened risk for adverse pregnancy outcomes, including preterm delivery, low birth weight, and infants who are small for gestational age. • It is crucial to emphasize pregnancy contraindications during follow-up appointments for patients on these medications. Access to a medical obstetrician team is invaluable in managing such cases. • While some case reports have documented positive pregnancy outcomes with other JAK inhibitors, such as tofacitinib and baricitinib, there remains a significant gap in knowledge regarding upadacitinib. This case report adds to the limited data on the potential risks associated with upadacitinib exposure during pregnancy. Comprehensive and targeted studies are necessary to better understand the safety of this class of drugs during pregnancy and lactation.

The introduction of a dedicated cardiology clinic including a clinical scientist led pathway for women with turner's syndrome

Abstract Background There are more than 15,000 women living with Turner’s Syndrome (TS) in the UK, over 700 of whom are cared for within our linked Endocrinology services. Mortality is predominantly related to cardiovascular disease therefore close cardiology review with a focus on aortopathy is essential (1). However appropriate surveillance is challenging with growing pressures on all aortopathy services across the United Kingdom. Purpose To audit our current practise according to current international guidelines (2) and seek methods to improve the pathway for our growing population of TS patients including the feasibility of a Clinical Scientist led clinic, aiming to improve capacity and efficiency of our service. Methods A quality improvement project was conducted over a three-year period, piloting a dedicated clinical scientist-led clinic under close Cardiology Consultant supervision. Patients selected were deemed lower risk for cardiovascular complications according to American Heart Association (AHA) recommendations (2) (figure 1). Follow-up intervals of patients under both consultant-led and clinical scientist led pathways were analysed. Results Among a total of 226 patients analysed, 103 (46%) fell into the lowest risk category and therefore deemed suitable for prospective Clinical Scientist led pathway (figure 2). Analysis of all patients demonstrated that 60% had appropriate follow-up intervals according to guidelines, while 37% were too short and 3% were too long. A five-year projection indicated a consequential 96 unnecessary additional appointments for patients that were being seen too frequently. Further analysis showed that the time frame for follow up was too short in 25% of patients seen in the clinical scientist led clinic compared to 41% in the Consultant-led clinic. There were no aortic dissections in patients under surveillance during this period. In the last 10 years 1 patient on the waiting list for surgery (having presented with a type B dissection but requiring workup for liver cirrhosis) had a retrograde type A dissection (indexed aortic root dimension 2.4cm/m²). No other adverse events were recorded. Conclusion Auditing our service revealed safe management and improved adherence to guidelines in the clinical scientist-led clinic, identifying opportunities to optimize follow-up and enable physicians to focus upon high-risk patients. This pilot demonstrates the feasibility of a clinical scientist-led clinic in managing low risk TS patients, suggesting scalability to other conditions involving aortopathy to address capacity issues and improve pathways.

Effects of COVID-19 on Irish general practice activity from 2019 to 2021: a retrospective analysis of 500,000 consultations using electronic medical record data.

General practice (GP) is crucial to primary care delivery in the Republic of Ireland and is almost fully computerised. General practice teams were the first point of contact for much COVID-19-related care and there were concerns routine healthcare activities could be disrupted due to COVID-19 and related restrictions. The study aimed to assess effects of the pandemic on GP activity through analysis of electronic medical record data from general practice clinics in the Irish Midwest. A retrospective, descriptive study of electronic medical record data relating to patient record updates, appointments and medications prescribed across 10 GP clinics over the period 2019-2021 inclusive. Data relating to 1.18 million record transactions for 32k patients were analysed. Over 500k appointments were examined, and demographic trends presented. Overall appointment and prescribing activity increased over the study period, while a dip was observed immediately after the pandemic's arrival in March 2020. Delivery of non-childhood immunisations increased sixfold as a result of COVID-19, childhood immunisation activity was maintained,while cervical smears decreased in 2020 as the screening programme was halted. A quarter of consultations in 2020 and 2021 were teleconsultations, and these were more commonplace for younger patients. General practice responded robustly to the pandemic by taking on additional activities while maintaining routine services where possible. The shift to teleconsulting was a significant change in workflow. Analysing routinely collected electronic medical record data can provide valuable insights for service planning, and access to these insights would be beneficial for future pandemic responses.

A-185 Impact Assessment of Centrifugation During Transportation on Examination Results

Abstract Background Laboratories are increasingly challenged to seek solutions to expedite the collection process and provide more convenience to patients. This study aims to validate the centrifugation of samples in transport cars for home collections without need to return to the basic unit after each sample collection for centrifugation using the traditional method for up to 2 hours, as recommended in the literature, providing an increase in the number of patient appointments and a greater portfolio of exams. Methods The study was carried out evaluating measurands that represent different methodologies and sample stability challenges, namely, PTH, free T4, testosterone, CA19.9, anti-HBS, anti-transglutaminase, LDH, potassium, glucose, sodium and alkaline phosphatase( FAL). The centrifuge used during sample transport was the Drucker, model Horizon - 6 Flex, calibrated and monitored during the study. Forty samples from volunteer patients were analyzed, with one tube centrifuged in the equipment installed in the car and a second tube in the basic unit's centrifuge within 2 hours of collection, both respecting the 30-minute clot retraction period. All tubes were sent to the same laboratory for execution. Results Throughout the study period, the calibration of the car's centrifuge remained stable. In the correlation, the variance, calculated by the F Test, showed an adequate result, below 1.69. The difference between the means of the test method and the comparative method calculated through the T Test was below the Critical T. The Pearson correlation for the mensurands Free T4, CA19.9, anti-transglutaminase, LDH, potassium, sodium and glucose was lower than the accepted limit of 0.950. Agreement analysis and Kappa index were performed and the data were evaluated from a qualitative point of view by the medical team, who considered the differences to have no clinical impact on the patient. PTH, CA19.9 and FAL were approved by the difference graph.In relation to glucose, the correlation between the serum-gel tube and fluoride was also evaluated, where we obtained lower results with the fluoride tube due to hemolysis caused by the additive. During the analysis of LDH results, a tendency to decrease the concentration of its dosages over time can be observed, and in this case there were lower results in samples centrifuged in the basic unit, due to the longer interval between collection and centrifugation. Conclusions After evaluation from a pre-analytical, quality and medical point of view, centrifugation from home samples collection directly in the car will allow a greater number of patients to be served, as there will be no need to return to the basic unit for centrifugation every 2 hours. It will also bring greater safety in centrifuging the sample at the correct time, avoiding any delays that may occur, mitigating potential deviations in results and greater process efficiency as the collector will not need to return to the basic unit for centrifugation, right during During the collection route, the samples will already be prepared for sending directly to the execution site. For glucose and LDH tests, it was possible to observe efficiency gains due to centrifugation 30 minutes after collection.

332 - Predictors of missed hospital appointments in patients with posterior compartment pelvic floor disorders in a tertiary referral center

332 - Predictors of missed hospital appointments in patients with posterior compartment pelvic floor disorders in a tertiary referral center

Impact of an institutional process change adopting end-systolic coronary CTA acquisition and automated dose selection on patient throughput and image quality

IntroductionGuidelines recommend prospective ECG-triggered mid-diastolic coronary computed tomographic angiography (CCTA) acquisition after achieving optimal heart rate (HR) control in order to optimize scan image quality. With dual-source CCTA, prospective end-systolic acquisition has been shown to be less prone to motion artifacts at higher heart rates and may improve scan and CT laboratory efficiency by allowing CCTA without routine pre-scan beta-blocker (BB) administration. MethodsWe implemented an institutional process change in CCTA performance effective January 2023, comprising a transition from prospective ECG-triggered mid-diastolic acquisitions individually supervised by a physician at the scanner to an algorithmic approach predominately utilizing prospective end-systolic acquisition (200–400 ​ms after R peak), employing an automated dose selection algorithm, without BB administration. All scans were performed on a third-generation 192-slice dual-source scanner. We reviewed 300 consecutive CCTAs done pre- and post-process change in Jan 2022 (phase 0), Jan 2023 (phase 1), and in May 2023 (phase 2) after implementation of a process improvement involving more selective utilization of automated tube potential/current algorithms (CARE kV) to optimize image quality. Coronary segmental image quality was assessed by two experienced CCTA readers by consensus using an 18-segment SCCT model on a 5-point Likert scale (1 ​= ​non-interpretable; 2 ​= ​poor; 3 ​= ​acceptable; 4 ​= ​good; 5 ​= ​excellent). Measures of radiation dose, medication administration, and time required for patient scanning were compared. Logistic regression was used to determine factors associated with patient-level reduction in image quality (IQ) and with repeat scans. ResultsPost-process change, there was a significant reduction in the median overall patient appointment [phase 0: 95 (75–125) min vs. phase 1: 68 (52–88) min and phase 2: 72 (59–90) min; P ​< ​0.001] and scan times [phase 0: 13 (10–16) min vs. phase 1: 8 (6–13) min and phase 2: 9 (7–13) min; P ​< ​0.001]. Median IQ score in both post-process change phases was 4 (4–5) compared to a median score of 5 (4–5) pre-process change (P for comparison <0.001). The majority of segments post-process change had “good” IQ (Phase 1 segmental IQ scores: 5 ​= ​36.7 ​%, 4 ​= ​46.8 ​%, 3 ​= ​13 ​%, 2 ​= ​2.6 ​%, 1 ​= ​0.9 ​%; Phase 2 segmental IQ scores: 5 ​= ​26 ​%, 4 ​= ​49.7 ​%, 3 ​= ​16.3 ​%, 2 ​= ​6.1 ​%, 1 ​= ​1.9 ​%), whereas pre-process change, the majority of segments had “excellent” IQ (Phase 0 segmental IQ scores: 5 ​= ​56 ​%, 4 ​= ​34.3 ​%, 3 ​= ​7.5 ​%, 2 ​= ​1.8 ​%, 1 ​= ​0.4 ​%) There was no significant increase in non-interpretable scans at the patient level. The 22 ​% re-scan rate in phase 1 (vs. 6 ​% in phase 0, P ​= ​.002) improved to 15 ​% in phase 2. While patient related factors of body mass index [adjusted OR obese 2.64, 95 ​% CI 1.12–6.51, P ​= ​0.03; aOR morbidly obese 6.94, 95 ​% CI 2.21–23.52, P ​= ​0.001] and average HR [aOR (per 10 bpm increase) 1.51, 95 ​% CI 1.21–1.9, P ​< ​0.001] were associated with the scoring of any segment as ​≤ ​3 ​at the patient level in a fully adjusted model, the improved phase 2 of the process change was not [aOR 1.61, 95 ​% CI 0.78–3.32]. ConclusionImplementation of an institutional process change utilizing prospective ECG-triggered dual-source end-systolic acquisition avoided the use of beta-blockers, significantly reduced patient appointment and scan times with acceptable diagnostic performance.

The cancer diagnostic clinic: A rapid access clinic to improve outcomes for patients with a suspected cancer diagnosis.

77 Background: Patients with suspected cancer often face challenges navigating complex health systems, resulting in delays in diagnosis and time to treatment, which are associated with adverse outcomes and patient dissatisfaction. To improve patient access and bridge this healthcare gap, the Cancer Diagnostic (CDx) clinic was established to streamline the evaluation for patients with a new suspected cancer. The CDx clinic prioritizes expedited cancer evaluation, timely and accurate diagnostic testing, and transition of care to subspecialty Oncologists, to improve the patient experience and cancer-related outcomes. Methods: Leaders in the Abramson Cancer Center (ACC) initiated a pilot project to facilitate timely appointments to Oncologists for patients in the Emergency Department with a new suspected cancer. Patient access lead time and time to diagnosis and treatment were tracked. This pilot was formally expanded across the health system to become the CDx clinic for eligible adult patients with suspicious symptoms, lab abnormalities, or imaging findings concerning for cancer. Patient data was extracted using an EMR-based form and supplemented by chart review. Study period was March 2023 to April 2024 and included socio-demographics, cancer subtype, referral type, time from referral to new patient appointment (access lead time), time from first appointment to diagnosis and treatment (surgery, systemic or radiation therapy), patient retention, complications, and mortality. Results: Over 12 months, 108 patients were evaluated in the CDx clinic. Most patients were male (56%), White (58%), and non-residents of Philadelphia County (65%). There were 8 referrals (range: 6-13) per month with the majority of patients from external referrals (60.2%). Compared to baseline, CDx resulted (median pre/post in days) in similar time to first appointment (7 vs. 7 days), improved time to diagnosis (21 vs. 8 days), and improved time to treatment (42 vs. 29.5 days). 71 patients were diagnosed with cancer with Gastrointestinal (47%) and Thoracic (24%) cancers being most common. 98.6% (70/71) of patients were retained at ACC and transitioned to subspecialty care. 80.3% (57/71) of patients received cancer-directed treatment. After the initial consult date, for the patients diagnosed with cancer, there were 4 ED visits and 20 hospitalizations within 30 days, 19 hospice enrollments, and 16 deaths. Conclusions: The CDx clinic has been a valuable resource for patients with suspected cancer by optimizing time to diagnosis and time to treatment. Additional navigation pathways are underway to expand the CDx patient population to target a more underserved population in an effort to promote health equity in cancer care.

Effect of a virtual oncology telemedicine advanced practice provider clinic on patient financial burden and access to care disparities in patients with new benign hematologic cancer.

388 Background: Anemia is a significant part of healthcare burden in the US with 2.8 million visits per year (CDC Stat Facts, 2024). In a large community oncology/hematology practice of 200+ physical clinics/cancer centers throughout Texas, meeting benign hematology patient needs is challenging. Due to ever-increasing specialty physician shortages, patients are experiencing extended appointment access times and increased financial burden related to travel for New Patient appointments. Patients were waiting an average of 15.1 days from referral to initial provider appointment. A statewide quality improvement pilot was created allowing clinic providers the option to refer benign hematology patients to a Virtual APP (VAPP) clinic for the New Patient visit. Methods: This retrospective endeavor collected electronic medical record data over a 90-day pilot period from January-April 2024, to evaluate the time between referral received vs appointment completion. Additionally, the referred patients’ distance from home location to the nearest in-person clinic was calculated. Results: Implementation of a virtual APP New Patient clinic reduced the time from referral to first appointment from 15.1 days to 9 days for a 40% reduction in time to appointment. Within the pilot, 129 patients on average, would have traveled approximately 44 miles round trip to and from their home residence to the closest in person clinic. This resulted in a minimum mileage cost savings of $9.68 per patient, $1,248 cumulative. Additionally, these same 129 patients saved approximately 3.5 hours of work time by not taking time off for commute resulting in a 96.39 per patient, $12,434.31 cumulative, earned incoming savings based on average Texas salary. Conclusions: The VAPP clinic reduced patient access disparity for Benign Hematology appointments by over 40%. Utilization of a telemedicine-based platform, at a minimum, reduced the patients’ financial toxicity burden and impact by 106.06 per patient or 13,682.31 overall during the 90-day pilot period. Providing a virtual visit option for patients, allows quicker access to quality care, lessens time toxicity, and reduces financial burden associated with medical care in 2024.

An integrated distributionally robust model for two-echelon patient appointment scheduling

We develop a distributionally robust optimization (DRO) model for the outpatient appointment scheduling problem of a set of patients served in two serial stages, consultation and examination. The arrival sequence of patients is known, and the problem of scheduling is to assign appointment time for each patient to minimize total cost with random service time for two serial stages. A max–min problem is formulated for the two-stage appointment scheduling as a whole, in which the waiting time exhibits a high degree of coupling due to the continuous two-stage process. To address this, we devise a two-stage network maximum flow model that provides an equivalent linear expression for the waiting time. For the inner maximum problem, we employ a conic programming approach for equivalent representation, incorporate the scheduling decision of the outer minimum problem, and convert the model to its equivalent copositive programming by taking the conic duality. We conduct numerical experiments and sensitivity analysis using real and simulated data, and the results verify the effectiveness of our proposed DRO model.

Access and adherence to cancer care through the Veteran Affairs Close to Me cancer care service.

111 Background: Diagnosing and treating more than 56,000 Veterans annually, the Veterans Affairs (VA) National Oncology Program (NOP) is one of the nation’s largest integrated providers of oncology services. Within VA, oncology care and parenteral therapies are primarily offered at VA Medical Centers (VAMCs) in urban areas, often inaccessible to rural patients. Issues with travel distance, parking, time, and caregiver support can prevent patients from adhering to treatment appointments as evidenced by historical annual No-Show rates for VAMC infusion clinics that range from 1.1-6.7%. To mitigate potential barriers to access, NOP launched the Close to Me (CTM) cancer care service. The service deploys Registered Nurses (RNs) to local VA Community Based Outpatient Clinics (CBOCs) to administer cancer treatments. VA has opened 23 CTM clinics across 5 geographical regions since October 2021. Methods: The CTM service was implemented at VAMCs with NOP providing direct project management, safety assessment and resources such as a comprehensive implementation toolkit, standard operating procedures, care coordination tools, a tiered risk drug matrix and a standardized Healthcare Failure Mode and Effect Analysis risk evaluation. RNs followed a standardized workflow to assess patient eligibility and verify treatment clearances. Access to care was reported by numbers of unique patients and treatment visits. Patient appointment adherence was monitored by no-show rates documented in the electronic health record. Infusion reactions and medical emergencies were reported by RNs. Travel miles saved was calculated by subtracting the difference in miles round trip from the patient’s home to main VAMC and from home to CBOC, then multiplied by number of treatment visits to CBOC. Results: From October 2021 through April 2024, 23 new CTM clinics opened across 5 regions. 515 unique patients were enrolled for a total of 1,916 patient visits. Treatment appointment no-show rate was 1% across all CTM clinics. The most commonly administered medication classes include gonadotropin-releasing hormone agonist (30%), immune globulin (14.5%), immune checkpoint inhibitors (9.3%) and bisphosphonates (8.3%). Zero infusion reactions or medical emergencies were recorded across 1,430 treatments administered. A total of 204,000 travel miles were saved by patients enrolled in this program. Conclusions: The CTM cancer care service safely optimizes current VA CBOC infrastructure to increase access points to oncology treatment for patients across various geographical regions. CTM reduced travel burden for patients and increased ability to adhere to treatment appointments as evidenced by the service’s low no-show rate. These consistent results across CTM services at VAMCs nationwide have cemented CTM as a safe and effective treatment delivery model to expand access. CTM will be scaled to an additional 30 regions by end of 2025.

Transition of care from pediatric to adult nephrology post-renal transplant: a review.

Pediatric renal transplant recipients (RTRs) face heightened risks when they transition from a childhood nephrologist to an adult-centered one. The transition of care usually occurs when an individual is between ages 18 and 21 years, although some change providers earlier or later depending on varying circumstances. Turbulence during this shift can significantly impact daily life and, in severe cases, lead to graft loss. Several modern studies have explored the transition from pediatric to adult-centered nephrology care post-renal transplant. In this review, we first provide an overview of the differences between pediatric and adult renal transplant, highlighting unique challenges faced by pediatric patients such as donor-recipient size disparity, growth impairment, and need for additional immunizations. We then emphasize the criticality of a well-planned transition process, identifying factors that can hinder a smooth transition-such as medical and medication nonadherence, lack of health literacy, patient psychosocial challenges, and systemic shortcomings in coordination between care teams. Furthermore, this review outlines existing protocols and risk assessment tools, in addition to highlighting recent advancements aimed at facilitating smoother transitions such as the RISE protocol, readiness assessment, and the use of multidisciplinary teams. Proper implementation of coordinated, evidence-based transition protocols can improve patient outcomes, promote medication and appointment adherence, and reduce graft rejection rates. Efforts from multidisciplinary teams utilizing technology, risk stratification tools, and open communication between providers and patients are key to optimizing the transition process for pediatric RTRs as they transfer to adult-centered care.

Scheduling Appointment for Patients’ Using PHP

Scheduling Appointment for Patients’ Using PHP

Views and perspectives toward implementing the Global Spine Care Initiative (GSCI) model of care, and related spine care program by the people in Cross Lake, Northern Manitoba, Canada: a qualitative study using the Theoretical Domain Framework (TDF)

BackgroundBack pain is very common and a leading cause of disability worldwide. Due to health care system inequalities, Indigenous communities have a disproportionately higher prevalence of injury and acute and chronic diseases compared to the general Canadian population. Indigenous communities, particularly in northern Canada, have limited access to evidence-based spine care. Strategies established in collaboration with Indigenous peoples are needed to address unmet healthcare needs, including spine care (chiropractic and movement program) services. This study aimed to understand the views and perspectives of Cross Lake community leaders and clinicians working at Cross Lake Nursing Station (CLNS) in northern Manitoba regarding the implementation of the Global Spine Care Initiative (GSCI) model of spine care (MoC) and related implementation strategies.MethodA qualitative exploratory design using an interpretivist paradigm was used. Twenty community partners were invited to participate in semi-structured interviews underpinned by the Theoretical Domains Framework (TDF) adapted to capture pertinent information. Data were analyzed deductively and inductively, and the interpretation of findings were explored in consultation with community members and partners.ResultsCommunity leaders (n = 9) and physicians, nurses, and allied health workers (n = 11) emphasized: 1) the importance of contextualizing the MoC (triaging and care pathway) and proposed new services through in-person community engagement; 2) the need and desire for local non-pharmacological spine care approaches; and 3) streamlining patient triage and CLNS workflow. Recommendations for the streamlining included reducing managerial/administrative duties, educating new incoming clinicians, incorporating follow-up appointments for spine pain patients, and establishing an electronic medical record system along with a patient portal. Suggestions regarding how to sustain the new spine care services included providing transportation, protecting allocated clinic space, resolving insurance coverage discrepancies, addressing misconceptions about chiropractic care, instilling the value of physical activity for self-care and pain relief, and a short-term (30-day) incentivised movement program which considers a variety of movement options and offers a social component after each session.ConclusionCommunity partners were favorable to the inclusion of a refined GSCI MoC. Adapting the TDF to unique Indigenous needs may help understand how best to implement the MoC in communities with similar needs.

Prevalence and severity of gag reflex in patients presenting at the department of prosthodontics.

Objective: To determine the prevalence and severity of gag reflex at initial appointment of patients visiting the department of Prosthodontics using the Gag Severity Index (GSI) tool proposed by Fiske and Dickinson. Study Design: Cross-sectional study. Setting: Department of Prosthodontics, Islamabad Dental Hospital, Islamabad. Period: 1st November, 2022 to 31st April, 2023. Methods: All the patients who presented in outpatient (OPD) of Prosthodontics with 18 to 85 years of age were included in this study. All the data of age, gender, educational levels and gag severity grades were noted on a predesigned proforma. Percentages and frequencies were calculated for all the data by using SPSS version 22. Results: A total of 150 (55.14%) patients out of 272 who gagged, were included in the study, with 61 (40.66%) males and 89 (59.3%) females, the gag reflex being more prevalent in female patients. The patients’ age range was from 18 to 85 years. In terms of gag severity grades in 150 patients, grade I was observed in 60 patients (40.0%), grade II in 49 patients (32.7%), grade III in 30 patients (20.0%), grade IV in 10 patients (6.7%) and grade V in 1 patient (0.7%). 40.0% of grade I patients were from 18-40 years age group and 51.6% were from 61-85 years age group. 37.0% of grade II patients belong to 41-60 years of age. In terms of qualification, 40.6% exhibited hyper active gag reflex in patients with university level or above. Conclusion: Female patients exhibit a higher prevalence of gag reflex than male patients, with grade I being the most common. While a definitive solution is yet to be established, effective patient education and dentist diligence can lead to productive management and future treatment exploration.

Prioritized appointment allocation in new patients, what is really decisive? : Comparative analysis of manual appointment allocation with automated and AI-assisted approaches

The timely allocation of appointments for new patients is a daily challenge in rheumatological practice, which can be supported by digital solutions. The question is to find the simplest and most effective possible method for prioritization when allocating appointments. Using a registration form for new patients, standardized symptoms and laboratory results were collated. After reviewing this information by a medical specialist the allocation of appointments was carried out in three categories: a) < 6weeks, b) 6weeks up to 3months and c) > 3months. The waiting time between the time of registration and the presentation appointment was calculated and compared between patients with and without a diagnosis of an inflammatory rheumatic disease (IRD). In addition adecision tree (DT), amethod taken from the field of supervised learning within artificial intelligence (AI), was established and the resulting classification was compared with respect to the accuracy and calculated saving in waiting time. In this study 800 appointments between 2020 and 2023 (including 555 women, 69.4%, median age 53years, interquartile range, IQR 39-63 years) were analyzed. An IRD could be confirmed in 409 (51.1%) cases with awaiting time of 58vs. 93days for non-IRD cases (-38%, p < 0.01). An AI-based stratification resulted in an accuracy of 67% for IRD and apredicted saving of 19% waiting time. The accuracy increased up to 78% with a time saving for IRD cases of up to 31%, when all basic laboratory results were known. Simplified algorithms, e.g., stratification by the use of laboratory findings alone, resulted in a lower accuracy and time savings. Manual allocation of appointments by a medical specialist is effective and significantly reduces the waiting times for patients with IRD. An automated categorization can lead to a reduction in waiting times for appointments when taking complete laboratory results and a lower sensitivity into consideration.