Cancellation Rate Research Articles

O-085 Patients support through a mobile application improves ART outcomes across all age groups

Abstract Study question Assess the effectiveness of fertility treatment companion mobile application, which provides tracking, adherence tools, education and community support, in improving ART outcomes Summary answer Results showed that patients use of mobile application during treatment had significantly improved ART outcomes compared to the CDC average, across all age groups What is known already Growing numbers of adults use digital health tools to diagnose and manage their health conditions. Direct-to-consumer, interactive, diagnostic apps with information and personalization capabilities beyond those of static search engines are rapidly growing in use (M. Millenson et al. 2018). A very limited amount of research has been conducted on mobile application’s ability to impact ART outcomes (I. Robertson, etc. 2021). Existing studies include small control groups and limited data. To date, though sparse, most research has focused on mobile applications’ and internet-based technologies' ability to mitigate the psychological effects of infertility (Meyers & Domar, 2021).Study design, size, duration: Retrospective analysis conducted using Embie mobile application’s database (EMU) between Jan 1, 2021 and Dec 31, 2022. Study group included 6449 cycles by 5067 users self-reported in real-time. EMU stimulation cycle cancelation rates and pregnancy outcomes, at week 20 of pregnancy, were compared to CDC 2020 preliminary report of LBR and stimulation cycle cancellation rates, divided into 4 age groups; <35, 35-37, 38-40 and >40. EMU population included 53% U.S., 47% out of U.S. Participants/materials, setting, methods Participants are fertility clinic patients globally who voluntarily downloaded the mobile application via the App or Play stores. The application provides ART cycle protocol tracking and monitoring, eggs retrieved, embryo, transfer and pregnancy results, etc, along with educational articles and community support. Self-reported data is entered in real-time by the user. We cleared, merged and analyzed using python, then compared the CDC report by age group. Chi square significance performed comparing two proportions (with continuity correction). Main results and the role of chance 4426 EMU of stimulation cycles analyzed 2319, 903, 683, 521 by age respectively. EMU stimulation cancelation rates 2.76%, 3.54%, 6.00%, 7.49% respectively. 2073 EMU transfer cycles analyzed 1078, 431, 336, 228 by age respectively. Ongoing EMU pregnancy at 20 weeks was observed in 618, 252, 170, 75 respectively. Ongoing EMU pregnancy rates at 20 weeks 57.33%, 58.47%, 50.60%, 32.89% respectively. Delta CDC/EMU stimulation cycle cancellation rate 5% vs 2.76%, 7.20 vs 3.54%, 10.10% vs 6.00%, 14.20% vs 7.49% respectively. Delta CDC LBR per transfer data vs EMU ongoing pregnancy 49.80% vs 57.33%, 45.50% vs 58.47%, 40.40%vs 50.60%, 23.90% vs 32.89% respectively. Delta CDC LBR per transfer data to EMU U.S. users’ only ongoing pregnancy 49.80% vs 62.86%, 45.50% vs 65.77%, 40.40% vs 58.17%, 23.90% vs 43.62% respectively. Statistically significant analysis by chi square score showed all delta measurements to be significant (p < 0.0001). Limitations, reasons for caution Self-reported data may not be as reliable as data collected in a clinical setting. However, the use of a large cohort reduces the impact of a single error. Additionally, LBR were compared to ongoing pregnancy at 20 weeks, which can influence the outcomes at a low rate. Wider implications of the findings Our results suggest that fertility treatment mobile applications can significantly improve ART outcomes and patient's experience. Clinics should consider adopting such tools as an adjunct to care. The ability to collect and analyze big data globally in real-time will impact future ART research, medical understanding and improvement of patient’s fertility treatment. Trial registration number not applicable

P-241 Cumulative live birth rates after embryo transfers at Day-2/3 versus Day-5/6: a comparative nationwide cohort study

Abstract Study question Are there significant differences between cumulative live birth rates (CLBR) after a short and an extended embryo culture when comparisons are performed per cycle? Summary answer The CLBR per cycle was significantly lower in the Day-5/6 group and higher per embryo transfer as compared with the Day-2/3 group. What is known already Previous evidence has shown the probability of live birth following a fresh embryo transfer in In Vitro Fertilization (IVF) is higher after extended embryo culture (E-EC: Day-5/6) than after a shorter embryo culture (S-EC: Day-2/3). A further controversy literature has arisen on cumulative pregnancy rates, related to the higher risks of embryo transfer cancellation after E-EC compared with S-EC. Moreover, all of these studies used slow freezing/thawing embryo protocols with a higher survival for Day-2/3 embryos than Day-5/6 embryos. Finally, a recent study combining vitrification highlighted CLBR improvements after E-EC but CLBR were expressed per embryo transfer, not per cycle. Study design, size, duration A French national register study including all IVF cycles with at least one cleaved embryo at day-2 performed in France from 01/2016 to 12/2018 was carried out (n = 165,808 cycles), after exclusion of gamete donation cycles, attempts with preimplantation genetic diagnosis, surgical spermatozoa, viral context, and for which the embryo freezing was performed by slow-freezing. We chose to include only cycles from IVF centers with standardized CLBR similar or above to the national mean (99%CI). Participants/materials, setting, methods From the biomedicine Agency’s registry, two groups were identified: cycles with embryo(s) at Day-2/3 with/without embryo transfer (S-Group) and cycles with all embryos cultured to Day-5/6 with/without embryo transfer (E-Group). The CLBR defined as delivery of at least one live-born infant in fresh or in subsequent frozen-thawed cycles were compared. Only the first delivery was considered. Regression model adjusted for women age, parity, Day-2 embryos, IVF-method and attempt rank was used. Main results and the role of chance In total, 48,293 attempts fulfilled the inclusion criteria. Among them, 31,769 cycles were included in the S-Group and 16,524 in the E-Group. Overall, the CLBR per cycle was significantly lower in the E-Group compared with the S-G group (32.9% versus 33.5%; aOR: 0.89, 95%CI [0.86-0.93], p<.0001). A significant higher rate of fresh embryo transfer cancellation was observed in in the E-Group compared with the S-Group (19.8% versus 3.1%, p < .0001). However, when we performed further comparisons restricted to data from IVF centers with LBR strictly significantly above to the national mean LBR, the CLBR were similar between both groups (36.4% versus 38.5% in S-Group and E-Group, respectively; aOR: 0.97 [0.90-1.04], p = 0.402). Finally, the CLBR in E-group was significantly higher than in S-group when expressed per embryo transfer (aOR: 1.15 [1.10-1.21], p<.0001). Limitations, reasons for caution Main limitations are: the retrospective design and the 1 year follow-up that could not include all frozen embryo cycles performed. Wider implications of the findings Overall, the nationwide results per cycle suggest that extended embyo culture until blastocyst stage, even used in combination with vitrification, could not improve live birth rates. Trial registration number not applicable

P-763 Intrauterine insemination following controlled ovarian stimulation with gonadotropins: how to lower the multiple pregnancy rate without decreasing the live birth rate ?

Abstract Study question What cancelation policy in controlled ovarian stimulation-intrauterine insemination (COS-IUI) cycles allows to lower the multiple pregnancy rate (MPR) without decreasing the live birth rate (LBR)? Summary answer An algorithm based on the woman’s age, serum Estradiol level and number of follicles ≥14 mm on trigger day reduces the MPR without impacting LBR. What is known already While the MPR in IVF cycles has significantly decreased in the past decades, it has remained stable and relatively high in COS-IUI cycles, at around 10-15%. The main reason behind this continuously high MPR in COS-IUI cycles has been the relative inability to lower it without significantly decreasing the overall pregnancy rates. Several risk factors are associated with MP in COS-IUI cycles, and recommendations have varied between the different scientific societies, but to date, there is no consensus on the best strategy to decrease the risk of MP in COS-IUI cycles without compromising the pregnancy and live birth rates. Study design, size, duration A bicentric observational cohort study at the Angers University Hospital (group A) and the Besançon University Hospital (group B) between January 2011 to December 2019. Approximately 350-400 IUI cycles are performed yearly in each center. All patients who had a clinical pregnancy following COS-IUI during the study period were included. Our main outcome measure was the MPR and our secondary outcome measures were the clinical pregnancy (CP), miscarriage and LBR. Participants/materials, setting, methods In group A, the starting gonadotropin dose was 50-100 IU/day, and the algorithm for cycle cancelation was based on the woman’s age, serum Estradiol (E2) level, and number of follicles ≥14 mm on trigger day. In group B, the starting gonadotropin dose was 100-150 IU/day and the cancelation policy was case-by-case and physician dependent, based on the woman’s age, number of follicles ≥15 mm, and number of previous failed COS-IUI cycles, without predefined cut-offs. Main results and the role of chance We included 6582 COS-IUI cycles (3387 in group A and 3195 in group B) that resulted in 884 clinical pregnancies (790 singletons, 86 twins and 8 triplets). The MPR was significantly lower in group A compared to group B (8.1% vs 13.3%, p = 0.01). The CPR (13.4% vs 13.4%, p = 0.99), the miscarriage rate (14.5% vs 15.6%, p = 0.64) and the LBR (10.8% vs 11.9%, p = 0.16) were comparable between groups A and B. Univariate analysis showed the following factors to be predictive of the risk of MP: the treatment center (OR = 1.73 [1.12-2.68]), the number of follicles ≥10 mm (OR = 1.22 [1.11-1.36]) and ≥14 mm on trigger day (OR = 1.43[1.20-1.70]). Multivariate analysis also showed the following factors to be predictive of the MP risk: the treatment center (aOR=1.63 [1.02-2.60]), the number of follicles ≥ 10 mm (aOR=1.20 [1.07-1.34]) and ≥14 mm on trigger day (aOR=1.39 [1.16-1.66]). The cycle cancelation rate was comparable between groups A and B (7.2% vs 7.2%, p = 0.93), while cycle cancelation rate for excessive response to COS was significantly lower in group A compared to group B (19.3% vs 35.9%, p < 0.001). The rate of divergence from cancelation protocol was significantly lower in group A compared to group B (0.09% vs 1.1% p < 0.001) Limitations, reasons for caution The main limitation of our study is the retrospective design. The algorithm needs to be tested in other populations for further validation. Wider implications of the findings The use of low starting doses of gonadotropins (50-100 IU/day), and the application of a strict algorithm that takes into account the woman’s age, serum E2 level and number of follicles ≥14 mm on trigger day allows to optimize the success rates of COS-IUI cycles Trial registration number Not applicable

P-671 Comparing clomiphene citrate/ flexible GnRH antagonist vs ultrashort flare GnRH agonist protocols for controlled ovarian stimulation in poor ovarian reserve patients

Abstract Study question How do Clomiphene citrate (CC)/ flexible GnRH antagonist and ultrashort flare GnRH agonist protocols compare in poor ovarian reserve patients (POSEIDON groups 3 & 4)? Summary answer In poor ovarian reserve patients, irrespective of age, use of CC / flexible antagonist vs ultrashort flare protocol significantly reduces gonadotrophin consumption and stimulation duration. What is known already Poor responders constitute 47% of ART patients and up to 65% of these have diminished ovarian reserve. Despite the various treatment options available, lack of good quality evidence to enable recommendation of a particular protocol or adjuvant continues to pose a challenge to their effective management. The need for multiple stimulations for pooling up embryos also makes effective cost of treatment an added concern in them. Study design, size, duration An open label, multi centric, randomized controlled study was conducted over a period of 1 year recruiting 116 women having AMH <1.2ng/dl and antral follicle count (AFC) <5 who were further analysed in POSEIDON 3 and 4 subgroups. Patients were randomized to 1 of 2 groups for controlled ovarian stimulation. Those with severe endometriosis, adenomyosis, autoimmune or metabolic disorders, sustained hyperprolactinaemia, congenital uterine malformations and with male partners having severe oligoasthenoteratozoospermia were excluded. Participants/materials, setting, methods Group A (55 women) received CC 100mg from D1-D5 with 300 IU human menopausal gonadotrophin (hMG) in a flexible GnRH antagonist protocol. Group B (61 women) underwent ultrashort flare protocol. 1mg leuprolide was administered from D1-D4 and 300 IU hMG given D2 onwards followed by flexible GnRH antagonist administration. Dual trigger with triptorelin and recombinant hCG was administered 35-36 hours before oocyte retrieval. Embryos cultured till D5 were vitrified for transfer at a later stage. Main results and the role of chance The two groups were well matched for baseline characteristics like age, BMI, AMH, duration of infertility, D2 AFC, estradiol and FSH levels. The mean total gonadotrophin consumption (3387.29 + 1082.5 vs 4407 + 1224.2, p value <0.01) and the duration of stimulation (10.71 + 2.52 vs 11.95 + 2.43, p value <0.01) were significantly lower in group A vs group B. The primary outcomes of median number of oocytes retrieved (4 vs 4, p value- 0.71) , M2 rate (3 vs 3, p value-0.91), fertilisation rate were similar in the two groups. The secondary outcomes of oocyte retrieval rate (103.05 + 42.97 vs 97.14 + 42.96, p value- 0.63), FORT (0.81 +0.68 vs 0.96 + 0.48, p value- 0.37) FOI (0.91 + 0.55 vs 0.92+ 0.54, p value 0.92), top quality embryo rate (0.53 + 1.1 vs 0.41 + 0.84, p value 0.61), cycle cancellation rate (26.22% vs 29.09%), implantation rate (23.63% vs 24.59%) and clinical pregnancy rate (21.31% vs 20%) were also similar in group A vs B respectively. A subgroup analysis of POSEIDON 3 versus POSEIDON 4 patients revealed similar outcomes with both the protocols in the two groups. Limitations, reasons for caution Small sample size of the cases limits the current statistical power of the study. Wider implications of the findings CC /flexible GnRH antagonist protocol is an effective alternative to ultrashort flare protocol in patients with poor ovarian reserve irrespective of their age. The lower gonadotrophin dosage required and shorter duration of stimulation observed make it a viable option in patients who might need multiple stimulations for pooling up embryos. Trial registration number Not applicable

P-683 Live birth rate following medicated frozen-thawed embryo transfer with or without GnRH-antagonist (Cetrotide) pituitary suppression. A randomised, controlled pilot trial

Abstract Study question Does the administration of GnRH-antagonist (Cetrotide) in medicated frozen-thawed embryo transfer (FET) cycles improve live birth (LBR) or cycle cancellation rate? Summary answer Live birth and cycle cancellation were similar with or without Cetrotide. However, cancellation for threatened ovulation was statistically significantly lower when Cetrotide was administered. What is known already During medicated FET, embryo and endometrial development must be synchronized, with endometrial window of implantation dependent on duration of progesterone. Suppression of spontaneous ovulation is key to maintaining synchrony. There are insufficient data regarding the use of supplementary pituitary suppression in medicated FET. A recent Cochrane review identified one small RCT comparing live birth rate between medicated FET with or without GnRH-agonist pretreatment. The study suggested benefit to GnRH-agonist, but cycles were not monitored for ovulation. One RCT compared GnRH-antagonist with agonist showing better clinical pregnancy rate with GnRH-antagonist. No published RCT has compared medicated FET with versus without GnRH-antagonist. Study design, size, duration We conducted an open, two-arm, single-centre, randomised, controlled trial comparing medicated FET with or without Cetrotide. Target recruitment was 300. However, the study was stopped due to the Covid-19 pandemic. Recruitment occurred between 23rd January 2019 and 11th March 2020 and ended at 161 participants. Analysis was undertaken on an intention-to-treat basis, with live birth rate (LBR) as the primary outcome. Participants/materials, setting, methods Patients were given oestradiol 2mg orally TDS. Once the endometrium was ≥7mm, vaginal progesterone was commenced, with FET on the sixth day of progesterone. The Cetrotide group were given Cetrotide 0.25mg SC OD from days 1-7. Urine pregnancy test was done 11 days following FET, with oestradiol and progestogen continued to 10 weeks gestation. Cycles were cancelled for “threatened ovulation” if daily urinary LH-surge testing was positive or an ovarian follicle (≥12mm) was growing. Main results and the role of chance 161 patients were randomised (Cetrotide: 76, no Cetrotide: 85). Six were withdrawn after randomisation (three withdrew consent, two did not start, one natural pregnancy). 155 participants started treatment (Cetrotide: 73, no Cetrotide: 82) and 140 had embryo transfer (Cetrotide: 68, no Cetrotide: 72). The LBR was similar between groups (Cetrotide: 39% (30/76), no Cetrotide (29/85): 34%; OR 0.79, 95% CI 0.42 - 1.51), as were pregnancy rate (42% versus 38%; OR 0.87; 95% CI 0.47-1.63), clinical pregnancy rate (52% versus 49%; OR 0.83; 95% CI 0.44 – 1.56), biochemical pregnancy rate (20% versus 24%; OR 1.25; 95% CI 0.44 - 3.58) and miscarriage rate (7% versus 10%; OR 1.55; 95% CI 0.24 – 9.97). In the Cetrotide group, 7% of cycles were cancelled, compared to 12% in the no Cetrotide group (NS). However, cancellation due to threatened ovulation was statistically significantly lower in the Cetrotide group, with 0% of cycles cancelled compared to 5% in the no Cetrotide group (OR 1.05; 95% CI 1.001 – 1.105). Baseline characteristics (age at oocyte retrieval, age at FET, parity, subfertility diagnosis, number of oocytes retrieved, number of viable blastocysts, proportion of IVF/ICSI, endometrial thickness, number of embryos transferred, embryo quality) were similar between groups. Limitations, reasons for caution The study is limited by the fact it was unblinded, undertaken at a single site and was underpowered for live birth due to early trial cessation. Wider implications of the findings Results suggest no effect of Cetrotide on LBR in medicated FET. There was a significantly higher risk of cycle cancellation due to risk of ovulation in patients not taking Cetrotide. This is clinically significant and requires further study, as cancelled cycles increase costs and duration to birth. Trial registration number EudraCT Number: 2018-001915-63

P-693 Retrospective evaluation of the effect of the implementation of the DIVINE dose-calculator in daily practice on ovarian hyperstimulation treatment risk and live birth rate

Abstract Study question Does the implementation of the DIVINE dose-calculator in routine care decrease treatment risk due to ovarian hyperstimulation whilst maintaining treatment efficacy? Summary answer The implementation of the DIVINE dose-calculator significantly decreases treatment risks caused by ovarian hyperstimulation, without affecting treatment efficacy in terms of live birth. What is known already Meta-analyses show that tailoring the gonadotropin starting dose did not affect live birth rates, but reduced treatment risks. The ORT iOS IPD-MA study group used individual participant data to develop and validate a model for ovarian stimulation in IVF/ICSI: the DIVINE dose-calculator. This model scored adequate for assessing hyperstimulation treatment risk and poor for predicting live birth. It provides clinicians an overview of risk percentages per gonadotropin starting dose, which aids in selecting an appropriate, personalized gonadotropin starting dose. This model should be implemented in routine care to confirm the true clinical effect on treatment risk and live birth results. Study design, size, duration Retrospective cohort study using pseudonymized data in two fertility centers in The Netherlands. The dose-calculator was implemented on 15th February 2021. Data from 36 months before and 12 months after implementation were collected. The dose-calculator included female age, AMH and GnRH-type in order to select a starting dose between 100-225 IU. Baseline characteristics and fresh cycle treatment outcomes were extracted from the patient file, checked and cleaned. Missing data were imputed 50 times. Participants/materials, setting, methods Subfertile women younger than 38 years, starting their first IVF/ICSI treatment cycle with follitropin alfa or beta were included. Couples who did not plan to receive a fresh embryo transfer, women diagnosed with PCOS and couples undergoing limited insemination or PGT were excluded. Intention-to-treat and per protocol analyses were completed. Inverse propensity weighting was applied to balance confounders. Weighted regression was then performed using general linear models or ordered logistic regression models. Main results and the role of chance 493 women were included, 401 in the standard group and 92 in the dose-calculator group (per protocol analysis). There was no difference in live birth rate before and after implementation: 25.4% vs 25.0% respectively (OR: 1.01, 95% CI: 0.6 – 1.71). Ovarian hyperstimulation treatment risk clearly decreased after the implementation of the dose-calculator from 11.3% in the pre-implementation period to 4.3% in the post-implementation period (OR: 0.27, 95% CI: 0.08 – 0,91), of which OHSS incidence declined from 6.8% to 0% after implementation. Pre-implementation, women stimulated 1.0 day shorter as compared to the post-implementation period (MD, CI: 0.25 – 1.75), and used 200 IU gonadotropins less per cycle (MD, 95% CI: 48.68 – 352.11). The cancellation rate due to low ovarian response were equal pre- versus post-implementation (OR: 0.94, 95% CI: 0.45 – 1.98) as well as the cancellation rate due to high ovarian response (OR: 0.56, 95% CI: 0.11 – 2.84). Post-implementation 1.05 less oocytes were collected during follicle aspiration (MD, 95% CI: -2.51 – 0.41), which resulted in 0.41 less usable embryos (MD, 95% CI: -1.04 – 0.17). The usable embryo per oocyte was comparable (MD: 0.003, 95% CI: -0.061 – 0.067). The intention-to-treat analysis confirmed these results. Limitations, reasons for caution Results are preliminary and based on single center data. We expect to finalize the analyses including approximately 100 patients from the second center and a cost-effectiveness analysis before ESHRE 2023. Unfortunately, cumulative cycle results including cryopreserved embryo transfers and subsequent treatment cycles are not available. Wider implications of the findings The dose-calculator aids in optimizing ovarian stimulation, without compromising live birth prospects. It is an easy to use model, which substantially reduces risks caused by ovarian hyperstimulation. A free of charge mobile application will be developed to stimulate implementation. Future research should address cumulative cycle results and temporal/geographical validation. Trial registration number Not applicable

O-295 Dual trigger does not improve reproductive outcomes in advanced maternal age women

Abstract Study question Could dual trigger increase oocyte yield and maturation rate in women of advanced maternal age (≥ 40) undergoing IVF? Summary answer Dual trigger does not result in higher oocyte yield or maturation rates compared to hCG monotrigger What is known already Advanced maternal age is related to poor ovarian response (POR) and remains a major therapeutic challenge in routine IVF practice, because of the association with low live birth rates and high cancellation rates. hCG is used at the end of controlled ovarian hyperstimulation as a surrogate LH surge to induce final oocyte maturation. Recently, the co-administration of GnRH agonist and hCG for final oocyte maturation (dual trigger) has been suggested to improve IVF outcome (by improving oocyte quantity and quality) in normal responders, while evidence in poor responders remains controversial. Study design, size, duration This is a retrospective cohort study including patients attending a private IVF clinic from 1st January 2018 until 1st June 2022. Participants/materials, setting, methods All women who underwent IVF/ICSI in antagonist protocol in our center were included. Patients may have undergone triggering of the final oocyte maturation either with 250mcg of rhCG or 0.2 mg of GnRH agonist. Mature oocytes were inseminated using ICSI. Main results and the role of chance In total, 2242 patients were included, 454 (20.2%) in the rhCG group and 1788 (79.8%) in the dual trigger group. There was no significant difference in female age [41.3 (1.12) vs 41.3 (1.19), p value 0.94]. Total stimulation units and duration were also comparable between groups. The number of oocytes and MII oocytes did not differ significantly between rhCG and dual trigger group [5.8 (4.1) vs 6.3 (4.7) and 4.7 (3.3) vs 4.9 (3.4), p = 0.15 and 0.49, respectively]. Maturation rates were similar 81.7% (22.4) and 79.8% (23.5), p = 0.15, as well as fertilization rates (defined as the number of oocytes fertilized divided by the total number of cumulus-oocyte complexes recruited) [57% (29.7) vs 58.8% (29.4), p value=0.2]. Embryo utilization rates (defined as the total number of embryos transferred and cryopreserved divided by the number of oocytes fertilized) were comparable between the two arms: 69.7% (34.2) vs 70% (33.9), p value =0.22. Multivariate Poisson regression analysis adjusting for relevant confounders (AMH, total stimulation units) showed that the type of triggering strategy (dual trigger vs rhCG) was not associated with either the number of MII oocytes (coefficient 0.2, p value=0.24) or maturation rates (coefficient -1.8, p value 0.12). Limitations, reasons for caution The main limitation is the retrospective design of our study, with an inherent risk of bias. Wider implications of the findings To the best of our knowledge, this is the largest study evaluating dual trigger strategy in advanced maternal age women. Our data demonstrate that dual trigger cannot improve the outcome of low prognosis women and should not be used as a panacea for all IVF patients. Trial registration number NA

Using Nudges to Reduce Missed Appointments in Primary Care and Mental Health: a Pragmatic Trial

BackgroundMissed appointments (“no-shows”) are a persistent and costly problem in healthcare. Appointment reminders are widely used but usually do not include messages specifically designed to nudge patients to attend appointments.ObjectiveTo determine the effect of incorporating nudges into appointment reminder letters on measures of appointment attendance.DesignCluster randomized controlled pragmatic trial.PatientsThere were 27,540 patients with 49,598 primary care appointments, and 9420 patients with 38,945 mental health appointments, between October 15, 2020, and October 14, 2021, at one VA medical center and its satellite clinics that were eligible for analysis.InterventionsPrimary care (n = 231) and mental health (n = 215) providers were randomized to one of five study arms (four nudge arms and usual care as a control) using equal allocation. The nudge arms included varying combinations of brief messages developed with veteran input and based on concepts in behavioral science, including social norms, specific behavioral instructions, and consequences of missing appointments.Main MeasuresPrimary and secondary outcomes were missed appointments and canceled appointments, respectively.Statistical AnalysisResults are based on logistic regression models adjusting for demographic and clinical characteristics, and clustering for clinics and patients.Key ResultsMissed appointment rates in study arms ranged from 10.5 to 12.1% in primary care clinics and 18.0 to 21.9% in mental health clinics. There was no effect of nudges on missed appointment rate in primary care (OR = 1.14, 95%CI = 0.96–1.36, p = 0.15) or mental health (OR = 1.20, 95%CI = 0.90–1.60, p = 0.21) clinics, when comparing the nudge arms to the control arm. When comparing individual nudge arms, no differences in missed appointment rates nor cancellation rates were observed.ConclusionsAppointment reminder letters incorporating brief behavioral nudges were ineffective in improving appointment attendance in VA primary care or mental health clinics. More complex or intensive interventions may be necessary to significantly reduce missed appointments below their current rates.Trial NumberClinicalTrials.gov, Trial number NCT03850431.

The Impact of Shortening the Matching Time on The Cancellation of Orders by Investors

This article mainly discusses the impact of the improvement of market transparency and liquidity on investor withdrawal behavior after the Taiwan Stock Exchange shortened the matching seconds from 10 seconds to 5 seconds. We use the intraday trading data of 5 months before and after December 2014 for actual measurement. We use the ratio of canceled orders as an indicator and use the paired sample T-test to examine whether there is a significant difference in the ratio of canceled orders between institutional investors and individual investors before and after the system change. The empirical results show that, except for the significant increase in the cancellation rate in Step 1 of legal persons and retail investors, all others have decreased significantly. Since the possibility of the cancellation in Step 1 being caused by manipulation is not high, it can be inferred that it is a purely wrong order, and the decrease in the ratio shows that the new system is helpful to the entire market, because investors have become more cautious when placing orders.

Disparities in medical oncology visit adherence among African American (AA) men with prostate cancer (pCa).

e18671 Background: AA patients (pts) with pCa tend to have worse outcomes when compared to Caucasians. Disparities in access to healthcare among AA pts with pCa is a significant barrier to improvement in outcomes. Medical oncology visit attendance among this population has not been thoroughly investigated. Methods: Pts with a diagnosis (dx) of pCa scheduled to see a provider (MD or advanced practice provider) at a single academic institution medical oncology clinic between January 2022 and December 2022 were retrospectively identified. Pts were categorized by self-identified race. The total number of scheduled clinic visits was recorded, and each visit was categorized by visit status; completed, cancelled, no-show, or left clinic. The reason for visit cancellation was assessed and cancelled visits for non-pt driven reasons (ie. scheduling error) were removed. The data were summarized using descriptive statistics. Z-test and Chi-square analysis were utilized to compare proportions of visits between AA and Caucasian pts and the association of race with visit status. Results: A total of 992 pts were selected, 80% (n = 792) were Caucasian and 16% (n = 162) were AA, representing 4231 clinic visits during the study period. AA pts accounted 18% (n = 763) of the total scheduled visits. 94% of visits (n = 3962) were follow up and 6% (n = 269) were new pt visits. 86% of all scheduled visits were completed and 10 % (n = 436) were cancelled for pt driven reasons. Roughly 3% (n = 135) of visits were no-show. AA pts had fewer completed visits compared to Caucasian pts, 78% vs 88% (p < 0.001) and a higher no-show rate of 10% vs 1.5% (p < 0.001). The cancellation rate was similar between AA and Caucasian pts, 11% vs 10% (p = 0.33). The combined no-show and cancellation rate for AA pts was 22% vs 12% for Caucasian pts (p < 0.001). There was a significant association between AA race and no-show visit status (p < 0.001). Conclusions: AA men with pCa have much poorer visit adherence to scheduled medical oncology visits compared to their Caucasian counterparts. Identifying reasons for no-show and visit cancellations and targeted interventions to improve access to care are needed to improve outcomes. [Table: see text]

Enhancing patient clinical streamlining (EPACS) pilot in the breast medicine service at memorial sloan kettering cancer center.

e18759 Background: Breast cancer patients at specialty cancer hospitals have a 10% lower risk of death in the first year vs those at community hospitals, where 77% of cancer patients are treated. However, there are barriers to seeking and following up care at the former. One intervention shown to favor continuity and reduce time to treatment has been ‘enhancing patient clinical streamlining’ (EPACS), which coordinates patient record-collection, care, expectations and therapy from initial contact. Methods: In this quality improvement project, we implemented EPACS in the breast outpatient service at a specialty cancer hospital. In lieu of the traditional sequence of nursing then doctors' visit followed by coordination of workup and subsequent therapy, EPACS involved an initial nursing visit followed by a telephone call from a provider (registered nurse, RN or advanced practitioner, APP) used to collect medical records/data, clarify patient expectations, and coordinate workup. Patients were then reviewed by MDs and treatment decisions were made. Phone calls were made to a subgroup of patients to assess satisfaction; and participating providers completed questionnaires regarding their experience of the pathway implementation. Results: The EPACS pilot was run at 8 clinics in parallel. In total 156 of 377 eligible patients (41.4%) were telephoned in a 6 month period. RN telephone calls lasted 15-60 minutes; while 82% of APP calls lasted > 60 minutes. 66 of these 156 (42.3%) were questioned on a separate phone call on their experience. Patient and MD satisfaction with EPACS was universally high: patients consistently reported that they felt better prepared and connected to their team after the calls. The majority of MDs felt that EPACS saved them time and increased overall efficiency. RN and APP responses were more mixed, with some feeling that calls were lengthy and overly broad in scope. Notably, only 19% of eligible patients were contacted prior to RN and practice-associated APP visits; vs 74% by per-diem APPs; hinting at time limitations. Cancellation and no-show rates were unchanged vs pre-EPACS, as were patient time in clinic; and time to first chemotherapy from first visit. There was no objective harm to patients with EPACS vs without. Conclusions: Although EPACS implementation in a busy breast outpatient service did not replicate prior findings of increased patient retention or reduced time to treatment; it did result in objective significant improvement in patient experience as judged by patient-reported metrics. Patients felt prepared, involved, and heard, though partially at the cost of staff time and workflow. Future work might aim to lighten the data-gathering aspects of the EPACS framework and focus instead on patient ideas, concerns and expectations, capitalizing on the observed benefits while limiting negative impact on time management experienced by some providers.

Pre-anaesthesia Telephone Consultation: A Safe Alternative for Anaesthesia Assessment in Case of Repeated Low or Intermediate Risk Surgeries: A Prospective Cohort Study.

Telemedicine has widely expanded during the coronavirus disease-2019 pandemic. Our objective was to evaluate the feasibility, safety, effectiveness, and satisfaction of pre-anaesthesia telephone consultation (PATC). From December 2015 to October 2016, a prospective survey was administered to anaesthesiologists, nurse anaesthetists, and patients of the ambulatory and maxillofacial departments. Patients having a pre-anaesthesia consultation (PAC) within the previous year in the department, whose health state was considered stable, and for whom the surgical procedure was related to the previous one, were eligible for PATC. Three questionnaires concerning the pre- (Q1), per- (Q2), and postoperative (Q3) periods were answered by the patient, the anaesthesiologist, and the anaesthesiologist nurse to evaluate the feasibility and satisfaction of the PATC. We collected the cancelation rate and any incident occurring during the surgery. Over the study period, 210 patients were included. The response rate was 200/210 (95.2%) for Q1, 108/208 (51.9%) for Q2 and 146/208 (70.2%) for Q3. PATC was performed in a median (IQR) of 13 (7-20) days before the procedure. Patients answered directly in 73% of cases without the need for recall. During surgery, 4 incidents occurred and none were attributable to PATC. Patient satisfaction was 93.3% and 85.8% of them preferred PATC to conventional PAC. The kilometric saving was 74 (30-196) km per PATC. Both patients and professionals were satisfied with PATC, which did not impact safety. On the selected patients, PATC brings many practical benefits and increases organizational flexibility.

Operating theatre efficiency at a tertiary eye hospital in South Africa

South Africa (SA) is a resource-limited country that needs efficient operating theatres in order for surgical care to function cost-effectively. Regular assessment of theatre efficiency in our setting is therefore needed. To describe ophthalmology theatre efficiency at a central hospital in SA and compare this with international benchmarks. St John Eye Hospital is the ophthalmology section of Chris Hani Baragwanath Academic Hospital in Soweto, SA. It has three operating theatres. A cross-sectional study was done of the theatres' registry of surgical procedures over a 6-month period. Data analysed included the starting and finishing times of theatre lists, surgical cases that were cancelled on the day of surgery, and theatre utilisation rates. These data were compared with international benchmarks. A total of 1 482 surgical procedures in 229 theatre lists were included in the study. Sixty-five percent of these theatre lists started late, accounting for 4 236 minutes of lost theatre time, significantly more than the maximum of 10% recommended by the Royal College of Anaesthetists. Of theatre lists, 23% and 30% finished after 16h15 (theatre overrun) and before 16h00 (theatre underrun), respectively. This is more than double the 10% recommended by the Royal College of Anaesthetists. The theatre utilisation rate was 62%, which is significantly lower than the ideal utilisation rate of 80%. The cancellation rate was 16%, which is significantly higher than the international benchmark of 2% recommended by the New South Wales guidelines. The most common reasons for cancellations were medical unfitness of the patient and lack of operating theatre time. All theatre efficiency parameters at St John Eye Hospital were below international benchmarks.

Managing Patient Anxiety in the Endoscopy Suite

BJ Olsen discusses how to lower the cancellation rate in the endoscopy suite using education and empathy

Predictors of Patient-Related Cancellations and No-Shows for Pediatric Orthopaedics and Sports Medicine Appointments Are Condition Specific

Background: Visit cancellations have detrimental effects on patient health and reduce clinic productivity. We sought to understand the factors that influence cancellation rates across the major subspecialties in pediatric orthopaedics and sports medicine (OSM).Methods: In-person OSM visits from a high-volume multi-site academic pediatric hospital (01/01/2019-02/28/2020) were used to study the effect of patient demographics, distance to clinic, insurance type, visit type (new vs. follow-up) on visit cancellation (canceled by patient and no-shows). When available, chief complaint was used to categorize visits into major subspecialties: cerebral palsy, foot and ankle, hip, knee, other lower extremity, spine, and upper extremity. Logistic regression was used to identify contributors to the visit cancellations in a multivariate model.Results: 424,397 visits (15.9% canceled) were included in the analysis. Based on the multivariate analysis, being non-white (OR=1.139), Hispanic (OR=1.133), older age (OR=1.007), female (OR=1.046), living farther from clinic (OR=1.002), and having public insurance (OR=1.163) were associated with higher cancellations, whereas median household income (OR=0.994, per $10,000) and new visit (OR=0.969) were associated with lower cancellations (P<0.04). 241,305 visits were categorized into subspecialties. The effects of studied patient-related factors and visit types on cancellations were highly variable across subspecialties. When significant, having public insurance and living farther from the clinic were consistently associated with higher rates of cancellations, while being a non-English speaker and having a new visit were associated with lower rates of cancellation. The remaining factors showed variable effects.Conclusion: Disparities exist in patient-related visit cancellations in pediatric and young-adult OSM with different patterns across major OSM subspecialties. These findings highlight the importance of looking at these specific orthopedic conditions separately to develop more effective strategies to improve patient compliance and efficiently utilize healthcare resources.Level of Evidence: Level IIIKey Concepts•Across all pediatric and young-adult OSM visits, being non-white, Hispanic, female, living farther from clinic, and having public insurance were associated with higher odds of cancellation.•While disparities exist in patient-related visit OSM care, the factors that influence cancellation in specific subspecialties are varied and complex.•Further research that looks at specific orthopedic conditions separately will improve efficiency and effectiveness of care and increasing patient compliance.

Surgical sperm extraction versus semen centrifugation: Method of spermatozoa recovery does not correlate with euploidy rates in patients with cryptozoospermia

Objective&#x0D; The aim of this study is to evaluate the rate of embryonic euploidy in blastocysts derived from testicular versus ejaculated sperm in cryptozoospermic patients.&#x0D; Design&#x0D; Retrospective cohort analysis.&#x0D; Material and methods&#x0D; The study included couples who suffer from Cryptozoospermia and underwent an autologous in vitro fertilization (IVF) with preimplantation genetic testing (PGT-A) cycle(s) from 2014 to 2019. Only cases where oocyte insemination was conducted with intra-cytoplasmic sperm injection (ICSI) were evaluated. Cohorts were separated based on the source of sperm (Ejaculated vs. Testicular (TESE)). Demographic and clinical embryology parameters were compared among cohorts. Student’s t-test, Wilcoxon’ rank test, chi-square test, and multivariate logistic regression fitted with a GEE model were used for data analysis.&#x0D; Results&#x0D; A total of 573 blastocysts derived from 87 IVF/PGT-A cases were included in the study. 74 cases (n= 474 embryos) utilized ejaculated sperm and 13 cases (n= 99 embryos) utilized testicular sperm. No significant differences were found in demographic and stimulation parameters among cohorts. (Table 1) No differences among the ejaculated and testicular cohorts were found in fertilization rate (63.2%; 61.1%, p=0.32); blastulation rate (64.5%; 66.6%, p=0.69); and rate of embryo euploidy (49.7%; 52.1%, p=0.76) respectively. No differences were found in rate of cycle cancellation due to unavailable embryos for TE biopsy (18.9% vs 7.6%, p=0.32).&#x0D; Conclusions&#x0D; There is no genomic advantage to surgical sperm retrieval in cryptozoospermic patients.

Application value of tumor necrosis factor inhibitors in in vitro fertilization-embryo transfer in infertile women with polycystic ovary syndrome

BackgroundClinical value of tumor necrosis factor (TNF) inhibitors in in vitro fertilization-embryo transfer (IVF-ET) in infertile women with polycystic ovary syndrome (PCOS) was investigated in this study.MethodsA retrospective analysis was performed on the clinical data of 100 PCOS patients who received IVF-ET for the first time at Hebei Institute of reproductive health science and technology from January 2010 to June 2020. The patients were divided into Inhibitor group and Control group according to whether they were treated with or without TNF inhibitors. Next, the two groups were subject to comparison in terms of the days of gonadotropin (Gn) use, total dosage of Gn, trigger time, hormone level and endometrial condition on the day of human chorionic gonadotropin (HCG) injection, the effects of two different regimens on controlled ovarian hyperstimulation (COH) and pregnancy outcomes.ResultsThere were no significant differences in baseline characteristics between the two groups, including age, duration of infertility, body mass index (BMI), ovarian volume, antral follicle count, and basal hormone levels. Compared with the Control group, the days of Gn use and trigger time of patients in the Inhibitor group were significantly shortened, and the total Gn dosage was notably reduced. In terms of sex hormone levels on the HCG injection, the Inhibitor group displayed much lower serum estradiol levels while higher serum luteinizing hormone and progesterone (P) levels than the Control group. Notably, the high-quality embryo rate was also significantly increased with the use of TNF inhibitors. However, significant differences were not observed in endometrial thickness (on the day of HCG injection), proportion of endometrial A, B and C morphology (on the day of HCG injection), cycle cancellation rate, number of oocytes retrieved, fertilization rate, and cleavage rate between the two groups. Importantly, the clinical pregnancy rate in the Inhibitor group was significantly higher than that in the Control group, but there was no significant difference in the biochemical pregnancy rate, early abortion rate, multiple birth rate, ectopic pregnancy rate and number of live births between the two groups.ConclusionCollectively, after application of TNF-α inhibitor regimen, superior overall treatment effect can be observed in infertile PCOS patients receiving IVF-ET. Therefore, TNF inhibitors have certain application value in IVF-ET in infertile women with PCOS.

Causal inference indicates that poor responders have similar outcomes with the antagonist protocol compared with flare

To use causal inference to investigate whether the flare or antagonist protocol is better for poor responders going through controlled ovarian stimulation. A retrospective study. Retrieval cycles from the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System. Patients in the United States underwent autologous invitro fertilization cycles from 2014 to 2019 using either the flare or antagonist protocol. Not applicable. Primary outcomes included oocytes retrieved, fertilized oocytes (2PNs), blastocysts, the cumulative live birth rate (CLBR), and cycle cancelation rate. After propensity score matching, patients with a predicted poor response (antimüllerian hormone, <0.5) on their first invitro fertilization cycle had similar outcomes on the antagonist protocol (CLBR of 14.2%, 95% confidence intervals [CIs]: 13.6%, 14.8%) compared with flare (CLBR of 13.6%, 95% CIs: 12.4%, 14.8%). We evaluated patients undergoing a second cycle after having a poor response (<4 oocytes retrieved) on their first cycle. Patients in the antagonist-to-antagonist group had a similar change in outcomes between the first and second cycles (average CLBR improvement of 13.9%, 95% CIs: 12.1%, 15.6%) compared with the antagonist-to-flare group (average CLBR improvement of 14.4%, 95% CIs: 10.9%, 18.3%). In addition, patients in the flare-to-antagonist group had a similar change in outcomes between the first and second cycles (average CLBR improvement of 10.4%, 95% CIs: 6.6%, 14.5%) compared with the flare-to-flare group (average CLBR improvement of 9.0%, 95% CIs: 5.1%, 13.4%). Poor responders have similar outcomes on an antagonist protocol compared with a flare protocol for both the first and second cycles.

Efficacy of Telehealth in Preoperative Pediatric Surgery Consultations

IntroductionThe Coronavirus disease 2019 pandemic created a sudden need to transition outpatient pediatric surgical care to a telehealth platform, allotting little time to study the efficacy of these changes. In particular, the accuracy of telehealth preoperative assessment remains unclear. Therefore, we sought to study the prevalence of errors in diagnosis and procedure cancellations between preoperative in-person evaluations and telehealth evaluations. MethodsWe conducted a single institution, retrospective chart review of perioperative medical records at a tertiary children's hospital over a 2-year period. Data included patient demographics (age, sex, county, primary language, and insurance), preoperative diagnosis, postoperative diagnosis, and surgical cancellation rates. Data were analyzed using Fisher's exact and chi-square tests. Alpha was set at 0.05. ResultsA total of 523 patients were analyzed, with 445 in-person visits and 78 telehealth visits. There were no demographic differences between the in-person and telehealth cohorts. The frequency of changes from the preoperative to the postoperative diagnosis was not significantly different between in-person preoperative visits and telehealth preoperative visits (0.99% versus 1.41%, P = 0.557). The frequency of case cancellations between the two consultation modalities was not significantly different (9.44% versus 8.97%, P = 0.899). ConclusionsOur results demonstrate that preoperative pediatric surgical consultations held via telehealth were neither associated with a decrease in the accuracy of preoperative diagnosis, nor an increased rate of surgery cancellations, compared to those held in-person. Further study is needed to better determine the advantages, disadvantages, and limitations of telehealth in the delivery of pediatric surgical care.

Global elective breast- and colorectal cancer surgery performance backlogs, attributable mortality and implemented health system responses during the COVID-19 pandemic: A scoping review.

Globally, 28.4 million non-emergent ('elective') surgical procedures have been deferred during the COVID-19 pandemic. This study evaluated the impact of the COVID-19 pandemic on elective breast- or colorectal cancer (CRC) procedure backlogs and attributable mortality, globally. Further, we evaluated the interaction between procedure deferrals and health systems, internationally. Relevant articles from any country, published between December 2019-24 November 2022, were identified through searches of online databases (MEDLINE, EMBASE) and by examining the reference lists of retrieved articles. We organised health system-related findings thematically per the Structures-Processes-Outcomes conceptual model by Donabedian (1966). Of 337 identified articles, we included 50. Eleven (22.0%) were reviews. The majority of included studies originated from high-income countries (n = 38, 76.0%). An ecological, modelling study elucidated that global 12-week procedure cancellation rates ranged from 68.3%-73%; Europe and Central Asia accounted for the majority of cancellations (n = 8,430,348) and sub-Saharan Africa contributed the least (n = 520,459). The percentage reduction in global, institutional elective breast cancer surgery activity ranged from 5.68%-16.5%. For CRC, this ranged from 0%-70.9%. Significant evidence is presented on how insufficient pandemic preparedness necessitated procedure deferrals, internationally. We also outlined ancillary determinants of delayed surgery (e.g., patient-specific factors). The following global health system response themes are presented: Structural changes (i.e., hospital re-organisation), Process-related changes (i.e., adapted healthcare provision) and the utilisation of Outcomes (i.e., SARS-CoV-2 infection incidence among patients or healthcare personnel, postoperative pulmonary complication incidence, hospital readmission, length of hospital stay and tumour staging) as indicators of health system response efficacy. Evidence on procedure backlogs and attributable mortality was limited, partly due to insufficient, real-time surveillance of cancer outcomes, internationally. Elective surgery activity has decreased and cancer services have adapted rapidly, worldwide. Further research is needed to understand the impact of COVID-19 on cancer mortality and the efficacy of health system mitigation measures, globally.