Outpatient Care Settings Research Articles

Evaluating the efficacy of tap water and commercial soap for outpatient wound management in simplified wound care

Managing wounds outside of hospital settings can be challenging due to limited knowledge, resources, and financial constraints. This study evaluates the safety and efficacy of using tap water and a commercial soap-based cleanser for wound care in outpatient settings. This prospective study enrolled 15 patients with open or surgical wounds. Participants used a commercial soap containing surfactants (decyl glucoside, sodium C14- 16 olefin sulfate) and tap water to cleanse their wounds. Exclusion criteria included severe systemic illnesses, uncontrolled diabetes, and immunosuppression. We monitored wound healing, infection rates, and complications over a 2-week period. The study examined wounds of various origins: surgical (n=9), traumatic (n=4), and infection-related (n=2). All wounds healed completely within 2 weeks, with no instances of infection, dehiscence, or delayed healing observed. These findings indicate that a straightforward soap-and-water cleansing regimen is both safe and effective for wound management. This study demonstrates that using tap water and commercial soap is a cost-effective and reliable strategy for wound management outside hospital settings. This approach has the potential to simplify wound care practices and reduce barriers to treatment, particularly in resource-limited environments.

P-626. Relative Vaccine Effectiveness of Cell-Based Versus Egg-Based Quadrivalent Influenza Vaccines Against Test-Confirmed Influenza in the United States 2022-23 Influenza Season

Abstract Background Egg-based influenza vaccine viruses often acquire egg-adaptive mutations in the hemagglutinin protein that can alter their antigenicity and may contribute to reduced vaccine effectiveness. Cell-based vaccine manufacturing avoids egg adaptation. We recently demonstrated improved effectiveness of cell-based quadrivalent influenza vaccines (QIVc) compared with egg-based quadrivalent influenza vaccines (QIVe) in preventing test-confirmed influenza during the 2017-18 to 2019-20 influenza seasons in the population aged 4-64 years in the United States. The objective of this study was to estimate the relative vaccine effectiveness (rVE) of QIVc versus QIVe in preventing test-confirmed influenza in an extended population aged 6 months to 64 years during the 2022-23 season in the United States. Methods The study applied a retrospective test-negative design among individuals aged 6 months to 64 years vaccinated with either QIVc or QIVe in 2022-23 and who had an influenza test obtained in routine outpatient care within +/- 7 days of a documented acute respiratory or febrile illness. Exposure, outcome, and covariate data were obtained from outpatient electronic health records linked to pharmacy and medical claims. rVE was estimated by comparing the odds of testing positive for influenza among QIVc recipients with the odds among QIVe recipients, using a doubly robust analysis. Sensitivity analyses included additional adjustment for the propensity to be tested, limiting to the peak influenza epidemic period, and matching on the test-week. Results The study included 43,086 tested patients, of whom 18.6% received QIVc and 81.4% received QIVe. QIVc was more effective than QIVe in preventing test-confirmed influenza in the outpatient care setting, with an estimated rVE of 7.7% (95% CI: 0.9% – 13.9%). Preliminary results of sensitivity analyses are consistent with the main analysis. Conclusion This study demonstrated superior effectiveness of QIVc compared to QIVe in preventing outpatient test-confirmed influenza in the population aged 6 months to 64 years during the 2022-23 season in the United States. These findings add to the body of evidence supporting improved effectiveness of cell-based versus egg-based influenza vaccines. Disclosures Alicia N. Stein, MBiostats, PhD, CSL Seqirus: Employee|CSL Seqirus: Stocks/Bonds (Public Company) Anusorn Thanataveerat, DrPH, Veradigm: Employee of Veradigm, which received a research contract to conduct this study with and on behalf of CSL Seqirus Kimberly McDermott, PhD, Veradigm: Employee of Veradigm, which received a research contract to conduct this study with and on behalf of CSL Seqirus Alex Dean, MPH, Veradigm: Employee of Veradigm, which received a research contract to conduct this study with and on behalf of CSL Seqirus Stephanie Wall, MPH, Veradigm: Employee of Veradigm, which received a research contract to conduct this study with and on behalf of CSL Seqirus Cory Pack, BS, Veradigm: Employee of Veradigm, which received a research contract to conduct this study with and on behalf of CSL Seqirus Ian McGovern, MPH, CSL Seqirus: Employee|CSL Seqirus: Stocks/Bonds (Public Company) Sheena G. Sullivan, PhD, CSL: Advisor/Consultant|Moderna: Advisor/Consultant|Novavax: Advisor/Consultant|Pfizer: Advisor/Consultant Mendel Haag, PhD, PharmD, CSL Seqirus: Employment|CSL Seqirus: Stocks/Bonds (Public Company)

Knowledge, Attitudes, Motivations, Expectations, and Systemic Factors Regarding Antimicrobial Use Amongst Community Members Seeking Care at the Primary Healthcare Level: A Scoping Review.

Antimicrobial resistance (AMR) is a major global health challenge, particularly in low- and middle-income countries (LMICs). Understanding the knowledge, attitudes, motivations, and expectations of community members regarding antimicrobial use is essential for effective stewardship interventions. This scoping review aimed to identify key themes relating to the critical areas regarding antimicrobial use among community members in primary healthcare (PHC), with a particular focus on LMICs. OVID Medline, PubMed, and CINAHL databases were searched using Boolean operators and Medical Subject Headings (MeSH) terms relevant to antimicrobial use and community behaviors. The Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework guided study selection, which focused on community members seeking care in PHC in LMICs. Data management and extraction were facilitated using the Covidence platform, with the Critical Appraisal Skills Programme (CASP) qualitative checklist applied for qualitative studies. A narrative synthesis identified and grouped key themes and sub-themes. The search identified 497 sources, of which 59 met the inclusion criteria, with 75% of the studies conducted in outpatient primary care settings. Four key themes were identified: (1) the 'patient' theme, highlighting beliefs, knowledge, and expectations, which was the most prominent (40.5%); (2) the 'provider' theme, emphasizing challenges related to clinical decision-making, knowledge gaps, and adherence to guidelines; (3) the 'healthcare systems' theme, highlighting resource limitations, lack of infrastructure, and policy constraints; and (4) the 'intervention/uptake' theme, emphasizing strategies to improve future antibiotic use and enhance access to and quality of healthcare. Stewardship programs in PHC settings in LMICs should be designed to be context-specific, community-engaged, and accessible to individuals with varying levels of understanding, involving the use of information and health literacy to effectively reduce AMR.

The year 2024 placed in perspective by hospital internists

This article presents a selection of ten key topics, carefully analyzed and commented on by chief residents at the Department of Internal Medicine at CHUV. This curated selection highlights the major advances and essential reminders in internal medicine for 2024. By reviewing this year's leading publications, it sheds light on progress in diagnostic and therapeutic approaches, both for hospitalized patients and the continuity of care in outpatient settings. From diabetes to cardiology, including gender medicine and nephrology, each area is examined with a focus on clinical innovations. This retrospective provides practitioners with a valuable resource to stay up to date with the latest developments, helping to improve the quality of care delivered to patients.

INPATIENT AND OUTPATIENT PALLIATIVE CARE AMONG VETERANS: THE NATIONAL LANDSCAPE

Abstract Palliative care (PC) improves quality of life for people with life-limiting conditions (LLC), which is common among older adults. In the United States, use of PC in the outpatient setting has expanded over the past decade; yet, most research has focused on inpatient PC. This study compared characteristics and use for veterans with inpatient or outpatient PC care nationally. The sample included veterans with specialty VA PC encounters, identified using VA and Medicare administrative data (2014-2017). Specialty PC encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99242-99245). Of 120,249 unique veterans with specialty PC, 67.8% had PC only in the inpatient setting (n=81,523) and 32.2% had at least one PC encounter in the outpatient setting (n=38,726). One third experienced the first PC encounter within 2 years of meeting LLC criteria. Outpatient versus inpatient PC users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; interquartile range, IQR =11, 112) and outpatient (median=44 days; IQR=14, 118) PC users, and shorter among those with only one PC encounter (median =18 days; IQR=5, 64). Among veterans with PC use, one third received at least some PC in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivates the need for further research to understand how care setting and timing of PC impacts outcomes for veterans and older adults.

Patient Experiences and Prerequisites of Collaboration as Partners in Person-Centred Care: An Interview Study.

To explore what characterises communication and collaboration within a patient and professional partnership in outpatient care settings garnered from the experiences of persons living with long-term conditions. A qualitative descriptive study design. Semi-structured individual interviews were conducted with 15 persons with long-term condition/s who experienced outpatient treatment or follow-up care. Data were explored through inductive thematic analysis. The COREQ checklist was followed. The analysis revealed five themes: adapting and self-managing in daily life, handling and carrying information, building trust and continuity, acting in a flexible and transparent dialogue and sharing the way forward. The participants described their personal and informal resources, and their actions to take control and manage health and well-being. A person-centred approach, sharing of knowledge and communication skills enabled the development of trust in the healthcare providers and their treatment and care. Communication was facilitated through availability, shared documentation, continuity and coordination of care. Collaboration was described as a flexible dialogue with mutual trust and transparency, shared learning and problem-solving. Sharing the way forward was a process, alongside and important to the life-changing process to cope with the illness. Prerequisites for the collaboration in outpatient settings were availability, continuity and a healthcare system that acknowledged, empowered and adapted to patients' health status, resources, everyday life and a patient's coping processes to manage their disease. For a co-created, person-centred outpatient care, it is important to acknowledge and/or collaborate with the patient's team of other healthcare providers and informal caregivers. The study contributes to better understanding of patient preferences and prerequisites how to work in partnership and how to develop future services and person-centred care for persons living with long-term conditions. Patients included in this study were participants during the data collection process.

Computer-assisted medical history taking prior to patient consultation in the outpatient care setting: a prospective pilot project

BackgroundFeeding patients’ self-reported medical history into the diagnostic care process may accelerate workflows in clinical routine.MethodsWe prospectively piloted a novel medical history documentation system in a German cardiological outpatient practice and evaluated its feasibility and perceived usefulness. Based on a generic software that allows to record structured information, a customized solution for the cooperating practice was developed and implemented. Prior to the consultation of the physician, the patient used a tablet that guided the user through a structured comprehensive workflow to document the medical history. The retrieved information was arranged by the software into a ready-to-use text format, presented to the physician in an editable form and added to her report. Three user-centered endpoints were explored: i) Appropriateness—measured by the duration of a patient interview; ii) Patient acceptance—assessed by three questions to patients; iii) Usefulness—operationalized by multiple ratings of the physician.ResultsA total of 2,513 patients were approached of which 2,415 provided complete histories. The system was assessed as appropriate for the practical workflow in terms of time and workflows. The patient-system interaction was rated favourably by patients including elderly ones. The system was regarded useful by the physician, reducing her daily workload by about one hour.ConclusionsAutomated history-taking tools deployed before consultation could support physicians in obtaining patients’ medical histories, thereby reducing professionals’ perceived workload. The technical and methodological limitations of our study should be respected, calling for additional future evaluations.

Medication reconciliation in the outpatient primary care setting: Barriers and opportunities.

Increased complexity of the health care system has led to challenges of vital communications, such as a current and accurate patient medication list. Medication reconciliation aims to create the most comprehensive and accurate list of a patient's current medications by comparing it with their electronic health record. However, effectively gathering, organizing, and communicating this medication information across different stages of care is often complex and challenging. Fragmented provider groups and incompatible software systems can also lead to breaks in communication and contribute to medication discrepancies. Medication reconciliation is an evidence-based safety intervention that can decrease medication errors and patient harm. Primary care providers play a critical role in ensuring a patient's medication list is current and accurate.

Epidemiological features of the spread of new coronavirus infection (COVID-19) in the Tomsk region in the first year of the pandemic

Introduction. At the end of December 2019 the World Health Organization (WHO) announced cases of pneumonia of unknown etiology. Soon, the disease received the official name “New coronavirus infection” (COVID-19), and the etiological agent was named the SARS-CoV-2 virus, characterized by rapid spread, high variability and diverse epidemic manifestations in various territories.Aim: To identify the epidemiological features of the spread of COVID-19 in the Tomsk region in the first year of the pandemic.Material and Methods. A descriptive epidemiological study was conducted in the Tomsk region in 2020. Information on COVID-19 cases was analyzed according to the federal register of persons with COVID-19, federal statistical observation form N 12 “Information on the number of diseases registered in patients living in the service area of a medical organization”. The assessment of the obtained data was carried out using the method of retrospective epidemiological analysis with subsequent statistical processing.Results. In connection with the threat of importation and spread of COVID-19 on the territory of Tomsk region, the order of the Administration of Tomsk region on January 31, 2020 approved the Plan of organizational sanitary and anti-epidemic (preventive) measures to prevent the importation and spread of a new coronavirus infection caused by 2019-nCoV. The first year of the COVID-19 pandemic was characterized by a wave-like course and significant fluctuations in morbidity during its different periods. Clinical manifestations of COVID-19 were registered in 91.2% of the diseased. The composition of patients was characterized by the prevalence of women (56.8%) compared to men (43.2%). The population mortality rate due to COVID-19 was 0.9%. In general, 74.3% of patients with COVID-19 received medical care in outpatient conditions. The capacity of the bed fund by the end of the first year of the pandemic in Tomsk region reached 2810 beds. The maximum coverage of population testing for SARS-CoV-2 identification was observed in the 46–47 calendar week, which corresponded to the maximum rise in COVID-19 morbidity among the total population.Conclusion. In the first year of the COVID-19 pandemic in Tomsk region, the following epidemiologic features can be distinguished: absence of seasonality; prevalence of patients with clinical manifestations of COVID-19 in the structure of the diseased; prevalence of patients requiring medical care in outpatient settings; involvement of patients aged 50–64 years in the epidemic process to a greater extent; prevalence of men aged 65 years and older among those who died due to COVID-19.

Blood pressure measurement technique in clinical practice in the NHS Greater Glasgow and Clyde.

Blood pressure (BP) measurement is a common procedure conducted in various disciplines and is widely available on clinical reports. The diagnosis and management of hypertension require reliable measurement of BP in outpatient clinics. Published studies suggest the standardised method for BP measurement is difficult to apply in routine clinical practice. This study aimed to assess the current practice of BP measurement in outpatient clinics in relevant secondary care clinical specialties across the 15 separate hospital sites of the NHS Greater Glasgow and Clyde region (population 1.2 million) compared to the recommended standardised method. An online questionnaire was developed and disseminated to the supervising clinician of each of 268 regular outpatient clinics. The questionnaire focused on the standardised BP method (patient preparation, environment, and BP measurement technique). The questionnaire was returned for 110 clinics. 73 (66.4%) of the participating clinics measure BP routinely and these formed the basis for further analysis. 3 clinics (4.1%) apply all components of the standardised BP method. 5 (6.9%) clinics deliver advice to patients prior to clinic attendance on how to prepare for BP measurement. 61 (83.6%) of participating clinics have a dedicated quiet environment for BP measurement. 50 (68.5%) clinics always place the cuff on bare upper arm and 63.0% use a cuff size appropriate to upper arm circumference. In a wide range of secondary care out-patient clinic settings, we found that BP measurement rarely adheres to the recommended standards. This has important implications for the quality of treatment decisions that are based on BP measurement.

Sexual revictimisation risk mitigation among survivors of sexual violence and trafficking: A multi-method feasibility study of a body-oriented treatment module

ABSTRACT Background The majority of sexual violence survivors become sexually revictimised, and migrant populations are at particular risk. Prior research indicates that limited body awareness, dissociation, and difficulties in communicating boundaries might be underlying mechanisms of sexual revictimisation. Mental healthcare disregarding sexual revictimisation may insufficiently address the population’s needs. Aims In the current study, a novel individually delivered body-oriented module was considered for its feasibility amongst migrant survivors of sexual violence and trafficking. Method Thirteen migrant sexual violence survivors engaged in the module in an outpatient mental health care setting in the Netherlands. A multi-method approach was applied to tap into patients’ and therapists’ perspectives on the feasibility of the module using pre-, during, and posttreatment questionnaires, evaluation forms, and (group) interviews. Results Patients and therapists reported treatment outcomes by the module’s aims, and treatment adherence was high. Bayesian informative hypothesis evaluation revealed that, for seven out of 12 patients (58.33%), body awareness, and self-efficacy in communicating boundaries increased, while body dissociation simultaneously decreased during treatment. Discussion Findings suggest that a body-oriented module for sexual revictimisation risk mitigation is feasible amongst migrant survivors. Given the small sample size and lack of a control group, the findings should be interpreted cautiously.

Evaluation of safety criteria for enoxaparin bridging in patients with left ventricular assist devices in an outpatient care setting.

Appropriate anticoagulation is crucial for the success of left ventricular assist device patients. Currently, there is no consensus on the optimal management of their subtherapeutic INR in ambulatory setting. Our goal is to evaluate both the short-term adverse events and long-term outcomes of enoxaparin bridging at a major transplant center, following the implementation of bridging safety criteria. In total, 85 patients' medical records were reviewed between 7/2019 and 5/2022, with 51 patients meeting safety criteria were bridged with enoxaparin and 34 non-bridged. The primary endpoint was the occurrence of major bleeding/thrombosis events within 30 days of bridging. The secondary endpoint was freedom from events 30 days after enoxaparin initiation and overall patient survivability until the last follow-up. Within 30 days, no major bleeding/thrombotic events were noted. After 30 days, the major bleeding rate was 5.8% in bridged vs. 11.8% in non-bridged patients (p = 0.02). Overall, 3-year survival was 78% in the bridged vs. 49% in non-bridged patients (p < 0.001). In patients with no events, 3-year survival was 80% in bridged vs. 58% in non-bridged (p < 0.001). In the patients with bleeding events, 3-year survival was 55% in bridged vs. 51% in non-bridged (p = 0.11). At 1 year, freedom from bleeding in the bridged patients was 81% in patients with no events vs. 0% in those with an event (p < 0.0001). When eligibility criteria for safe bridging were applied, the use of enoxaparin bridging was associated with no major bleeding/thrombotic events during bridging and improved 3-year survival in LVAD patients. Economically, using outpatient enoxaparin resulted in substantial healthcare savings, fewer readmissions, and improved quality of life.

Service evaluation: HRT regimens prescribed for complex menopausal patient cases

Abstract Introduction With government and NHS drivers, there has been an increase in menopause awareness and management. The NHS Business Services Authority reported a 29% increase in hormone replacement therapy (HRT) prescribing between 2022-2023, with expectation that this would rise further with introduction of the new HRT prepayment certificate in April 20231. Partly due to celebrity sway and supported by national guidance2,3 there is patient expectation towards transdermal oestrogen with natural progesterone HRT. Older women, some years since undergoing natural menopause, are also seeking advice on HRT use (3) with referrals accepted by specialist menopause clinics. Aims This service evaluation project was undertaken to evaluate the prescribing of HRT regimens in complex patient cases seen within a specialist menopause clinic and included assessment of those advised to use natural progesterone as part of their HRT regimen, for endometrial protection2,3. Method 366 specialist menopause clinic appointments over 6 months (05.01.23-22.06.23) were retrospectively evaluated, with patients seen by a multidisciplinary team within an outpatient secondary care setting. Exclusion criteria included appointments not attended, those that were incorrectly booked or patients with inaccessible records. Data was collected using electronic patient records with results analysed using Microsoft Excel. Results Of 327 (89%) appointments evaluated, the patient age ranged between 30-84 years (median age 53). HRT was recommended for 288 (88%) patients. HRT was not recommended in cases such as antiphospholipid syndrome, breast cancer without genitourinary symptoms, in those of advanced age or in line with patient choice with patient decision not to take HRT after an individualised risk benefit evaluation. For 26 (9%) patients, only topical oestrogen treatment for localised genitourinary syndrome symptoms was advised. 171 (52%) patients were postmenopausal, 61 (19%) perimenopausal, 46 (14%) with premature ovarian insufficiency and 20 (6%) with surgical menopause. For 22 patients (7%) with Mirena intra-uterine system in situ, their menopause phase could not be accurately defined. 243 (88%) of those recommended HRT were advised a combined regime; 154 (53%) continuous combined; 67 (23%) sequential combined and 22 (9%) oestrogen with Mirena coil. For patients accepting combined HRT, one third (81) were recommended natural progesterone, with the other patients using progestogens for endometrial protection. Of these 81 patients, 77 (95%) were recommended transdermal oestrogen in combination with natural progesterone. For patients recommended natural progesterone, 68 (84%) were for doses in line with licensing and current British Menopause Society guidance. For 10 patients the off-label recommendation involved doubled doses of natural progesterone to help with control of unfavourable bleeding. Discussion For prescribing of natural progesterone, we assumed that our recommendations to the GP were enacted. With retrospective evaluation of patient letters as a limitation, this project identified that within our specialist clinic complex patient population, a recommendation for natural progesterone was made for one third of patients suitable for combined HRT use. When not prescribed in line with licensing, this was due to issues with vaginal bleeding. Acknowledgments Biranavi Kirupakaran, Sahil Misri, Hernani Almeida, Medical Students, Imperial College London for data collection.

Veterans' use of inpatient and outpatient palliative care: The national landscape.

Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters). This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010-2017) to describe veteran demographics, socioeconomic status, life-limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241-99245). Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (n = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (n = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64). This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one-third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults.

Prevalence, Patterns, and Predictors of Oral Morbidity in Patients With Diabetes: Evidence From the Longitudinal Ageing Study in India.

Background Diabetes mellitus (DM) and periodontal disease share a complex bidirectional relationship, resulting in worsening of oral health with persistent impairment of glycemic control. Objective The objective of this study was to ascertain the burden, patterns, and predictors of oral morbidities in older patients with DM, including their health-seeking behavior in India. Materials and methods We used the nationally representative Longitudinal Ageing Study in India (LASI) wave-1 dataset (2017) to analyze data from 8,564 patients with DM aged ≥45 years. Results The median duration of DM in the participants was eight years. The weighted prevalence of at least one or more self-reported oral health morbidities was 59.85% (95% CI: 56.57% to 63.13%) including tooth pain (33.47%), loose teeth (29.98%), swelling in gums (10.08%), and bleeding gums (9.1%). Furthermore, patients with DM had a substantial burden of total (8.84%) and partial edentulism (66.35%). On adjusted analysis, female gender, higher educational status, higher wealth quintile, tobacco use, alcohol use, and greater duration of DM had significantly higher odds of having oral health morbidities excluding caries. Only 79 (0.12%) patients reported visiting dentists in the previous 12 months. Conclusions Integration of oral healthcare services with existing diabetes care in outpatient settings should be strengthened to improve oral health related quality of life.

Interdisciplinary perspectives on accessing specialty evidence-based treatment for Medicaid-insured adolescents with eating disorders

BackgroundFamily-based treatment (FBT), the leading intervention for adolescents with anorexia nervosa (AN), is severely understudied in outpatient care settings that serve publicly-insured populations. Many individuals with public insurance are lower-income, racially and ethnically diverse, and experience barriers to accessing evidence-based interventions for eating disorders (EDs).MethodsSemi-structured interviews were conducted with ten interdisciplinary providers who provide specialty care to youth with EDs in an inpatient and/or outpatient medical setting. Interview questions were focused on the interdisciplinary providers’ experiences of caring for individuals with EDs, with a focus on differences in care for those with private insurance compared to public insurance. The interviews took place two years after training in FBT was delivered to mental health providers in San Francisco County, which created opportunities to explore provider perspectives on collaborating with newly-trained mental health providers in the community implementing FBT with publicly-insured youth.ResultsContent analysis converged on three themes: the critical importance of supporting mental health treatment within the context of medical care, complex challenges when helping patients and their families navigate publicly-funded health care systems, and the overall positive impact of the FBT rollout in San Francisco County. Participants emphasized greater confidence in patient outcomes when collaborating with FBT providers and noted discord when working with providers not trained in EDs or FBT. Referral systems, weight-based stigma, and a lack of appropriate services were highlighted as significant barriers to care. To facilitate treatment engagement in publicly-insured populations, participants stressed the importance of clinicians providing psychoeducation and providing services with a high degree of cultural competence. Participants expressed that patients’ ability to access FBT and providers’ ability to collaborate on cases markedly improved following the county training, increasing their sense of efficacy in delivering adequate patient care.ConclusionsThe discussed themes highlight the importance of access to FBT for individuals in underserved communities, which can significantly reduce both provider and patient burden. Despite various barriers to utilizing FBT in publicly-funded settings, clinicians stressed that cultural adaptations increase the implementation of and facilitate family engagement in FBT, which is consistent with previous literature examining evidence-based intervention implementation science.

LEGAL AND ORGANIZATIONAL FRAMEWORK FOR OUTPATIENT PREVENTION OF DANGEROUS ACTS OF PERSONS WITH MENTAL DISORDERS

The article deals with prevention of dangerous acts of persons with mental disorders by medical organizations providing mental health care in outpatient settings. Outpatient preventive activities cover two patient groups: those who have not previously committed dangerous acts (primary prevention) and those who have committed such acts. In the latter case prevention concerns repeated dangerous acts (secondary prevention). The main means of outpatient primary prevention are diagnostics of mental disorders and provision of qualified outpatient mental health care. Outpatient care is provided in the form of regular assessment and treatment and in the form of dispensary observation, established regardless of consent of the mentally disordered person or his/her legal representative. Active dispensary observation is established for patients who have a propensity to commit socially dangerous acts. Such observation belongs to measures of both primary and secondary psychiatric prevention and is carried out by outpatient medical organizations in cooperation with the Interior authorities. Another means of outpatient secondary prevention is execution of a compulsory medical measure, such as compulsory observation and treatment by a psychiatrist in outpatient settings. The author, on the basis of studying legal acts, special literature and medical statistics, comes to the conclusion about increasing importance of prevention of dangerous acts of persons with mental disorders by medical organizations providing mental health care in outpatient settings.

A machine learning tool for identifying newly diagnosed heart failure in individuals with known diabetes in primary care.

We aimed to create a predictive model utilizing machine learning (ML) to identify new cases of congestive heart failure (CHF) in individuals with diabetes in primary health care (PHC) through the analysis of diagnostic data. We used a sex- and age-matched case-control design. Cases of new CHF were identified across all outpatient care settings 2015-2022 (n=9098). We included individuals 30years and above, by sex and age groups of 30-65years and >65years. The controls (five per case) were sampled from the individuals in 2015-2022 without CHF at any time between 2010 and 2022, in total 45 490. From the stochastic gradient boosting (SGB) technique model, we obtained a rank of the 10 most important factors related to newly diagnosed CHF in individuals with diabetes, with the normalized relative influence (NRI) score and a corresponding odds ratio of marginal effects (ORME). Area under curve (AUC) was calculated. For women 30-65years and >65years, we identified 488 and 3240 new cases of CHF, respectively, and men 30-65years and >65years 1196 and 4174 new cases. Among the 10 most important factors in the four groups (divided by sex and lower and higher age) for newly diagnosed CHF, we found the number of visits 12months before diagnosis (NRI 44.3%-55.9%), coronary artery disease (NRI 2.9%-7.8%), atrial fibrillation and flutter (NRI 6.6%-12.2%) and 'abnormalities of breathing' (ICD-10 code R06) (NRI 2.6%-4.4%) were predictive in all groups. For younger women, a diagnosis of COPD (NRI 2.7%) contributed to the predictive effect, while for older women, oedema (NRI 3.1%) and number of years with diabetes (NRI 3.5%) contributed to the predictive effect. For men in both age groups, chronic renal disease had predictive effect (NRI 3.9%-5.1%) The model prediction of CHF among patients with diabetes was high, AUC around 0.85 for the four groups, and with sensitivity over 0.783 and specificity over 0.708 for all four groups. An SGB model using routinely collected data about diagnoses and number of visits in primary care, can accurately predict risk for diagnosis of heart failure in individuals with diabetes. Age and sex difference in predictive factors warrant further examination.

Predicting buprenorphine adherence among patients with opioid use disorder in primary care settings

BackgroundMedications for opioid use disorder (MOUD), including buprenorphine, are effective treatments for opioid use disorder (OUD) and reduce risk for overdose and death. Buprenorphine can be prescribed in outpatient primary care settings to treat OUD; however, prior research suggests adherence to buprenorphine in these settings can be low. The purpose of this study was to identify the rates of and factors associated with buprenorphine adherence among patients with OUD in the first six months after a new start of buprenorphine.MethodsData were extracted from the electronic health record (EHR) from a large integrated health system in the upper Midwest. Patients with OUD (N = 345; Mean age = 37.6 years, SD 13.2; 61.7% male; 78% White) with a new start of buprenorphine between March 2019 and July 2021 were included in the analysis. Buprenorphine adherence in the first six months was defined using medication orders; the proportion of days covered (PDC) with a standard cut-point of 80% was used to classify patients as adherent or non-adherent. Demographic (e.g., age, sex, race and ethnicity, geographic location), service (e.g., encounters, buprenorphine formulations and dosage) and clinical (e.g., diagnoses, urine toxicology screens) characteristics were examined as factors that could be related to adherence. Analyses included logistic regression with adherence group as a binary outcome.ResultsLess than half of patients were classified as adherent to buprenorphine (44%). Adjusting for other factors, male sex (OR = 0.34, 95% CI = 0.20, 0.57, p < .001) and having an unexpected positive for opioids on urine toxicology (OR = 0.42, 95% CI = 0.21, 0.83, p < .014) were associated with lower likelihood of adherence to buprenorphine, whereas being a former smoker (compared to a current smoker; OR = 1.82, 95% CI = 1.02, 3.27, p = .014) was associated with greater likelihood of being adherent to buprenorphine.ConclusionsThese results suggest that buprenorphine adherence in primary care settings may be low, yet male sex and smoking status are associated with adherence rates. Future research is needed to identify the mechanisms through which these factors are associated with adherence.

Assessment of dietary intake in patients with metabolic dysfunction-associated steatotic liver disease using the Ukrainian version of the EPIC-Norfolk Food Frequency Questionnaire: A cross-sectional study

Metabolic dysfunction‑associated steatotic liver disease (MASLD) is prevalent worldwide. Studies demonstrate a possible association between diet and MASLD. However, data regarding patients in Ukraine are lacking. Objective — to study dietary habits and meeting recommended dietary intake in patients with MASLD. Materials and methods. Adults with MASLD aged 18 years and older (n=29) receiving care in outpatient settings who fully completed the adapted and validated Ukrainian version of the EPIC‑Norfolk Food Frequency Questionnaire (FFQ) were included in the analysis. Liver steatosis was confirmed by ultrasound examination, and diagnosis of MASLD was based on the criteria defined by the American Association for the Study of Liver Diseases. As a reference for recommended dietary intake, data from the Dietary Guidelines for Americans, 2020—2025 years were used. FETA software was used to calculate nutrient data from the FFQ. The one‑sample t‑test, t‑test, the one‑sample signed rank sum test, and Mann‑Whitney test were used to assess the differences between the sample and the reference data. The chi‑squared test was used to analyse categorical data. Results. The mean age of participants was 41.4±12 years, 69% of participants being female. The mean body mass index was 35.4±7.9 kg/m2. Participants consumed more protein, than recommended by current dietary recommendations. Women also tended to have higher energy intake and consume more fat, saturated fatty acids, and carbohydrates than recommended. The median fibre intake was 19.36 g (Q1; Q3 : 13.29; 26.45), which is lower than the recommended 14 g per 1000 kcal (p=0.0015). Dietary intake of most vitamins and micronutrients was met. However, women and men consumed less than 600 IU of vitamin D daily. Among all patients with MASLD, sodium intake (3829.5±1559.3 mg) was significantly higher than recommended (2300 mg, p&lt;0.0001). Approximately 62% of participants take dietary supplements, with vitamin D being the most popular choice. Conclusions. Our study showed that patients with MASLD in Ukraine tend to exceed recommended protein and sodium intake and, at the same time, have low fibre and Vitamin D consumption. High energy intake and saturated fatty acids consumption are also of concern.