Care Physicians Research Articles

Time taken for cardiology care and one-year results for primary care physicians' referrals for cardiology consultation in heart failure patients: clinical implications for heart failure management

Abstract Background and Purpose The clinical trajectory of patients with heart failure (HF) is characterised by frequent episodes of decompensation requiring urgent medical assistance, hospitalisations, and an increased risk of mortality. HF clinical guidelines recommend early visits by health professionals after hospital discharge, yet little evidence exists regarding the associations between delayed medical attention and outcomes in HF patients. To assess the clinical impact of the time taken to receive cardiology care for referrals from primary care physicians (PCPs) to a cardiology department in HF patients, we selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021. Methods Using an interrupted time series regression model, we analysed the impact of integrating e-consultations into the healthcare model (implemented in 2013) and evaluated the time taken to receive cardiology care, as well as all-cause, cardiovascular (CV), and HF-related hospital admissions and mortality. The primary objective of this analysis was to examine the associations between delays in cardiology care following a PCP referral and 1-year outcomes (HF-related, cardiovascular, and total hospitalisations; and HF-related, cardiovascular, and total mortality). Results Almost 50% were women, and the mean age was 77.8 years. Arterial hypertension (79.6%), diabetes (34%), atrial fibrillation (51.4%), ischemic heart disease (20.4%), and cerebrovascular disease were the most prevalent comorbidities. The mean time from PCP referral to cardiology consultation in the overall population was 22.3 days: <8 days in 53.9%, 8-14 days in 17.1%, 15-30 days in 15.9%, and >30 days in 13.0% of patients, respectively. One year after cardiology consultation, 68.6% of patients required assistance in an Emergency Department; 22.5% were hospitalised for any cause, 14.9% for cardiovascular reasons, and 9.2% for HF-related issues. Moreover, total mortality at 1-year was 8.6%, comprising 4.3% cardiovascular mortality and 1.3% HF-related deaths. Multivariate analysis of the relationship between the time taken to receive cardiology care and 1-year outcomes revealed a significant increased risk associated with a longer delay in cardiology assistance, particularly evident in the subgroup of patients with previous hospital admissions due to worsening HF (see Table). Conclusions Throughout the follow-up period, a reduced time taken to receive care was independently associated with better 1-year outcomes. We believe that our experience can contribute to the development of a more efficient ambulatory care pathway for HF patients, especially those at high risk, such as those with a history of hospitalisation due to worsening events. Our findings further support the clinical guideline recommendation for early contact by health professionals following hospital discharge, extending it to include PCP referrals for cardiology consultations.

Remnant cholesterol, clinical characteristics and mortality in 41.767 patients from LIPIDOGRAM 2004-2015 studies - the factor analysis for mixed data cluster analysis

Abstract Introduction Remnant cholesterol (remnant-C) contributes to residual cardiovascular risk and is produced by metabolism of triglyceride rich proteins. Aim To assess association between clinical characteristics of patients with elevated remnant-C in a large cohort of patients under the care of primary care physicians. Methods The LIPIDOGRAM studies were carried out in the primary care in Poland in 2004, 2006 and 2015. Patients (n=47,398) recruited in all 16 administrative regions in Poland and physicians were proportionally distributed to the number of inhabitants in each administrative region. Each patient was asked to fill the questionnaire on risk factors, chronic diseases, treatment and lifestyle. In the present analysis we included patients with body mass index (BMI )>18.5 kg/m2 aged 18-75 years. We set the cut-off point of fasting remnant cholesterol at >30 mg/dL (>0.77 mmol/L) that differentiated subjects at high risk of cardiovascular events. We carried out Factor Analysis for Mixed Data (FAMD) cluster analysis to discern groups of patients with similar clinical profiles. Results 41,767 patients, for which we had all relevant data, were included in the analysis. Follow-up rate was 97.8%. Three FAMD-derived clinical characteristics patterns accounted for 47.8% of the total variance and were retained for further analysis. The first pattern was associated with higher prevalence of metabolic syndrome (MetS), higher waist circumference, higher levels of non-HDL-C and remnant-C levels. The second pattern was distinguished by lipid parameters, particularly higher HDL-C levels, and was not significantly associated with comorbid conditions. The third pattern was linked to male sex, previous myocardial infarction, smoking, age, lower remnant-C levels, and reduced prevalence of obesity. All patterns were associated with 5-year mortality. The hazard ratio (HR) for mortality per 1 standard deviation (SD) increase in the first pattern score was 1.18 (95% CI: 1.16-1.22, p<0.001). Patients with clinical characteristics corresponding to second pattern had more favorable outcome HR (per 1SD score increase) – 0.75, 95%CI (0.73-0.78, p<0.001). Patients in third cluster, similarly to patients in cluster 1 had increased mortality HR (per 1SD score) – 1.10, (95%CI:1.06-1.15, p <0.001). Higher (>0.77 mmol/l / 30 mg/dl) remnant-C cholesterol significantly contributed to classification of patients into first and third clusters. It was positively associated with first pattern (r=0.64, p<0.001), but negatively with the third pattern (r=0.39, p<0.001). Conclusions Elevated Remnant-C was associated with clinical pattern typical for metabolic syndrome. Interestingly, lower remnant-C levels in patients with comorbidities and more advanced age may not automatically be indicative of a better prognosis – this requires further investigation.Figure 1.Figure 2.

Area-level socioeconomic status impacts healthcare visit frequency by Australian inflammatory arthritis patients: results from the Australian Rheumatology Association Database.

Individuals with inflammatory arthritis (IA) require long-term rheumatologist care for optimal outcomes. We sought to determine if socioeconomic status (SES) influences general practitioner (GP) and specialist physician visit frequency and out of pocket (OOP) visit costs. We linked data from Australian Rheumatology Association Database (ARAD) participants with rheumatoid arthritis or psoriatic arthritis to the Pharmaceutical Benefits (PBS) and Medicare Benefits Schedule (MBS) from 2011-2018. Small-area SES was approximated as quintiles of the Index of Relative Socieconomic Advantage and Disadvantage. A comorbidity index (Rx-Risk) was determined from PBS data. Analysis was performed using panel regression methods. We included 1916 ARAD participants (76.3% rheumatoid arthritis, 71.1% women, mean [SD] age 54 [12] years and disease duration 6 [4] years). Participants averaged 9.0 (95% CI 8.6, 9.4) annual GP visits and 3.9 (3.8 to 4.1) annual specialist physician visits. After adjustment for sex, age, education, remoteness and comorbidity, there was an inverse relationship between annual GP visit frequency and higher SES quintile (-0.6 [-0.9, -0.3] visits/quintile) and a direct relationship between more frequent specialist visits and higher SES (linear slope 0.3 [0.2, 0.5] visits/quintile). Average OOP costs/visit were higher for specialist physician (AUD$38.43 [37.34, 39.53] versus GP visits (AUD$7.86 [7.42, 8.31], and higher SES was associated with greater OOP cost. Higher SES patients have relatively fewer GP visits and more specialist physician visits compared with lower SES patients, suggesting lower SES patients may receive suboptimal specialist physician care. OOP costs may be a contributing factor.

The Population-Centered Medical Model: a method of practice for public health physicians

Abstract Background Public Health Physicians (PHPs) in Canada occupy a liminal space between medicine and public health. Current practice frameworks for the care of individual patients by physicians do not account for the complexity of working with communities and populations for health. Similarly, frameworks for public health practice do not account for the roles and responsibilities of physicians in public health. A method of practice that outlines how public health physicians care for populations is vital for training and development of practice for this specialty group within medicine and public health. Methods Constructivist Grounded Theory methods were used in this study. Ethics approval was obtained through The Western University Health Sciences Research Ethics Board. Semi-structured interviews were conducted with eighteen (18) currently practicing PHPs across Canada. Data was analysed iteratively using constant comparison, multi-level coding, and memo writing. Thick description and reflexivity were employed to enhance rigour. Results The key finding is the elucidation of the Population-Centered Medical Model. In this empirically grounded model, PHPs bring values, knowledge and stances to their practice of Public Health Medicine. PHPs consider the population as patient, along with ethical obligations that flow from the physician to the population as a consequence. The process of caring for populations involves both diagnosis and intervention, with a focus on systems and prevention. It relies on knowledge sharing and relationship building between the physician and the population. Conclusions This is the first empirical model to describe the practice of PHPs. The model firmly grounds PHP practice in both medicine (diagnosis and intervention, the construction of a patient) and public health (focus on populations, systems and prevention). It also presents an opportunity to develop a general model of medical practice for n patients, where n can range between 1 and N. Key messages • The Population-Centered Medical Model is an empirically grounded model that describes the work of Public Health Physicians in Canada and grounds practice firmly in medicine and in public health. • Public Health Physicians consider populations as patients. They diagnose and intervene for health, with a focus on systems and prevention, by building relationships and sharing knowledge.

Physician Altruism and Spending, Hospital Admissions, and Emergency Department Visits

Altruism-putting the patient first-is a fundamental component of physician professionalism. Evidence is lacking about the relationship between physician altruism, care quality, and spending. To determine whether there is a relationship between physician altruism, measures of quality, and spending, hypothesizing that altruistic physicians have better results. This cross-sectional study that used a validated economic experiment to measure altruism was carried out between October 2018 and November 2019 using a nationwide sample of US primary care physicians and cardiologists. Altruism data were linked to 2019 Medicare claims and multivariable regressions were used to examine the relationship between altruism and quality and spending measures. Overall, 250 physicians in 43 medical practices that varied in size, location, and ownership, and 7626 Medicare fee-for-service beneficiaries attributed to the physicians were included. The analysis was conducted from April 2022 to August 2024. Physicians completed a widely used modified dictator-game style web-based experiment; based on their responses, they were categorized as more or less altruistic. Potentially preventable hospital admissions, potentially preventable emergency department visits, and Medicare spending. In all, 1599 beneficiaries (21%) were attributed to the 45 physicians (18%) categorized as altruistic and 6027 patients were attributed to the 205 physicians not categorized as altruistic. Adjusting for patient, physician, and practice characteristics, patients of altruistic physicians had a lower likelihood of any potentially preventable admission (odds ratio [OR], 0.60; 95% CI, 0.38-0.97; P = .03) and any potentially preventable emergency department visit (OR, 0.64; CI, 0.43-0.94; P = .02). Adjusted spending was 9.26% lower (95% CI, -16.24% to -2.27%; P = .01). This cross-sectional study found that Medicare patients treated by altruistic physicians had fewer potentially preventable hospitalizations and emergency department visits and lower spending. Policymakers and leaders of hospitals, medical practices, and medical schools may want to consider creating incentives, organizational structures, and cultures that may increase, or at least do not decrease, physician altruism. Further research should seek to identify these and other modifiable factors, such as physician selection and training, that may shape physician altruism. Research could also analyze the relationship between altruism and quality and spending in additional medical practices, specialties, and countries, and use additional measures of quality and of patient experience.

Best Practices: Burnout Is More Than Binary.

Burnout among radiologists is increasingly prevalent, with the potential for having a substantial negative impact on physician well-being, delivery of care, and health outcomes. To evaluate this phenomenon using reliable and accurate means, validated quantitative instruments are essential. Variation in measurement can contribute to wide-ranging findings. This article evaluates radiologist burnout rates globally and dimensions of burnout as reported using different validated instruments; it also provides guidance on best practices to characterize burnout. Fifty-seven studies published between 1990 and 2023 were included in a systematic review, and 43 studies were included in a meta-analysis of burnout prevalence using random-effects models. The reported burnout prevalence ranged from 5% to 85%. With the Maslach Burnout Inventory (MBI), burnout prevalence varied significantly depending on the instrument version used. Among MBI subcategories, the pooled prevalence of emotional exhaustion was 54% (95% CI, 45-63%), depersonalization was 52% (95% CI, 41-63%), and low personal accomplishment was 36% (95% CI, 27-47%). Other validated burnout instruments showed less heterogeneous results; studies using the Stanford Professional Fulfillment Index yielded a burnout prevalence of 39% (95% CI, 34-45%), whereas the validated single-item instrument yielded a burnout prevalence of 34% (95% CI, 29-39%). Standardized instruments for assessing prevalence alongside multidimensional profiles capturing experiences may better characterize radiologist burnout, including change occurring over time.

Incidence of cardiovascular disease in a cohort of mine workers exposed to ultrafine aluminum powder in Ontario, Canada.

A retrospective cohort study was conducted to estimate associations between an ultrafine aluminum powder, McIntyre Powder (MP), and cardiovascular disease incidence in a cohort of mine workers from Ontario, Canada. Disease outcomes included ischemic heart disease (IHD), acute myocardial infarction (AMI), congestive heart failure (CHF), and strokes and transient ischemic attacks (STIA). Using work history records from the Ontario Mining Master File (MMF) mine workers were followed for disease incidence in administrative health records. The analysis included 25,813 mine workers who were exposed to MP between 1943 and 1979 and followed for cardiovascular disease (CVD) diagnoses between 2006 and 2018. Cardiovascular disease cases were ascertained using physician, hospital, and ambulatory care records. Poisson regression models were used to estimate age and birth-year adjusted incidence rate ratios (RR) and 95% confidence intervals (CI) for associations between MP exposure and CVD outcomes. Ever-exposure to MP was positively associated with modest increases in the incidence rate of IHD, AMI, and CHF, but not STIA, using both assessment approaches. Duration of self-reported MP exposure was positively associated with monotonically increasing rates of IHD and AMI compared to never-exposed miners, with the greatest association observed among miners with >20 years of exposure (for IHD: RR 1.24, 95% CI: 0.91-1.68; and for AMI: RR 1.52, 95% CI 1.01-2.28). Mine workers ever-exposed to MP had modestly elevated rates of CVD. The rate of CVD diagnoses appeared to increase with longer duration of exposure when assessed by both self-reported exposure and through historical records.

Integrated model of secondary fracture prevention in primary care (INTERCEPT): protocol for a cluster randomised controlled multicentre trial

BackgroundOsteoporotic fractures signal severely compromised bone strength and are associated with a greatly increased risk of refracture. Despite the availability of effective and safe medications that reduce fracture risk, 70–80% of patients are inadequately investigated or treated for osteoporosis following an initial fracture, constituting a significant ‘osteoporosis care gap’. Optimal methods of bridging this gap with primary care at the forefront of secondary fracture prevention remain undetermined. This protocol describes a cluster randomised controlled trial to evaluate the effectiveness of a novel integrated model of secondary fracture prevention and management in primary care.MethodsThe cluster randomised controlled trial involves multiple branches of a community-based radiology provider (CRP), a hospital-based secondary fracture prevention program (SFPP) and numerous primary care practices in metropolitan Sydney that refer to either the CRP or SFPP. Using natural language processing tools, patients diagnosed with a potential osteoporotic fracture will be identified by automatically screening radiology reports generated at the CRP or SFPP. The primary care practices that these patients attend will be randomised (1:1) to either the intervention or usual care. The intervention consists of (i) electronic and fax alerts informing the practice/primary care physician that their patient has been diagnosed with a potential osteoporotic fracture; (ii) provision of osteoporosis management guidelines and (iii) follow-up surveys at 4 weeks and 6 months. Practices in the usual care (control) group will receive no alerts and provide usual care. The primary outcome is the proportion of patients undergoing a bone density scan and/or filling a prescription for osteo-protective pharmacotherapy within 3 months of the initial diagnostic imaging report. Secondary outcomes are the proportion of patients: (i) undergoing an osteoporosis-related blood test within 3 months of the initial diagnostic imaging report; (ii) initiated on a chronic disease management plan within 3 months of the diagnostic report, and (iii) filling a second prescription for osteo-protective pharmacotherapy within 9 months post initial diagnostic imaging report. Outcomes will be obtained through de-identified linked data from Medical Benefits Schedule and Pharmaceutical Benefits Scheme held by the Australian Institute of Health and Welfare.DiscussionThis is the first randomised trial to integrate case-detection of potential osteoporotic fractures in a hospital and community setting with direct alerts to the patient’s primary care provider. This study will determine whether such an intervention is effective in improving investigation and/or treatment rates of osteoporosis in patients with a potential osteoporotic fracture.Trial registrationThis study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623000658617p.

“I would have to walk around to find the best Wi-Fi connection…”: qualitatively exploring challenges associated with rapid rollout of telehealth in Canadian long-term care homes

BackgroundEarly in the COVID-19 pandemic, long-term care (LTC) homes in British Columbia, Canada, restricted visitation to ensure the safety of their residents against transmission of the novel coronavirus. As such, these LTC homes had to quickly implement a rapid rollout of telehealth services to maintain physician care for residents while avoiding the infection risk of in-person visits amidst lockdown measures. The abrupt transition from traditional in-person physician care to telehealth presented significant challenges. Investigating these challenges is pivotal to the development of strategies for sustained telehealth use for physician services in LTC homes. This analysis is part of a broader qualitative, utilization-focused evaluation study of telehealth services rapidly implemented for physician care in LTC homes within the Fraser Health Authority region of British Columbia. The evaluation has aimed to consider integral factors such as telehealth challenges, facilitators, preferences, and continued use. Semi-structured interviews and focus groups were conducted with 70 physicians, staff, residents, and family caregivers across 27 different LTC homes in the region. All interviews and focus groups were transcribed verbatim and were analyzed using a thematic approach to identify common barriers surrounding the rapid rollout of telehealth in LTC across relevant groups.ResultsFrom the data, four challenges were identified: connectivity challenges (e.g., inconsistent or no Wi-Fi or cellular connectivity), device challenges (e.g., lack of accessible devices and software issues), privacy challenges (e.g., lack of private space to support telehealth use), and informational challenges (e.g., lack of electronic medical record access). All challenges posed barriers to telehealth access for both care provider and recipient groups in LTC settings.ConclusionsThe challenges identified in this analysis are supported by existing literature, which is significant given the different contexts within which such research has been undertaken. Collectively, this knowledge base can support evidence-informed improvements to telehealth for physician care in LTC settings. Future research should capture the perspectives of diverse cultural groups, LTC residents with cognitive impairments, and those who provide and receive care in rural settings.

The Role and Importance of Physician and Health Care Professional Programs

Physician Health Programs (PHPs) have been support­ing and advocating for health professionals for nearly four decades. Initially developed by state medical societies in the 1980s, PHPs recognized the need for therapeutic alterna­tives to disciplinary measures for physicians facing health issues that could impair their ability to practice safely. Originally focused on substance use disorders, PHPs have since expanded their services to encompass mental health and other co-occurring conditions.

Trends in payments for facility and surgeon professional fees for shoulder surgeries performed at ambulatory surgery centers

It has previously been demonstrated that utilization of ambulatory surgery centers (ASCs) results in cost savings and improved outcomes. Despite these benefits, Medicare reimbursement for professional fees at ASCs are decreasing over time. In this study, we sought to analyze the discrepancy between facility fee and professional fee reimbursements for ASCs by Medicare for common shoulder procedures over time. We hypothesized that professional fees for shoulder procedures would decrease over the study period while facility fees kept pace with inflation. Current Procedural Terminology (CPT) codes were used to identify shoulder specific procedures approved for ASCs by Centers for Medicare and Medicaid Services (CMS). Procedures were grouped into arthroscopic and open categories. Publicly available data from CMS was accessed via the Medicare Physician Fee Schedule Lookup Tool and used to determine professional fee payments from 2018-2024. Additionally, Medicare ASC Payment Rates files were accessed to determine facility fee reimbursements to ASCs from 2018-2024. Descriptive statistics were used to calculate means and percent change over time. Compound annual growth rates (CAGR) were calculated and discrepancies in inflation were corrected for using the Consumer Price Index. The Benjamini and Hochberg method was used to correct P values in the setting of multiple comparisons. A total of 33 common shoulder procedures were included for analysis (10 arthroscopic codes and 23 open codes). Reimbursements for facility fees have remained significantly higher than corresponding professional fees for both open and arthroscopic procedures (p<0.01). On average, facility fee reimbursements for common shoulder surgeries have risen on an annual basis in a manner consistent with inflation (p=0.838). However, professional fees for these procedures have experienced a nearly uniform decline over the study period both nominally and in inflation-adjusted dollars (p=0.064 and p=0.005, respectively). Facility fee payments for outpatient approved shoulder surgeries have matched or outpaced inflation. Over the same time period, professional fee reimbursements for surgeons are consistently decreasing, both in absolute and inflation-adjusted dollars. Reform to the physician fee schedule is necessary to ensure that Medicare patients retain access to high-quality physician care.

Primary care physicians’ experiences of video and online chat consultations: a qualitative descriptive study

Objectives To explore the perceptions and views of remote consultations and patient care of primary care physicians (PCPs) who work remotely regularly and have experience performing remote consultations. Design A qualitative study using thematic analysis. Setting Four online focus group interviews with 17 PCPs, working with one private health care provider, with public and private primary care patients. Subjects PCPs who had performed video or online chat consultations with primary care patients for at least 6 months. Main outcome measurements PCPs’ perceptions and views working remotely in online chat and video consultations. Results Two main themes describing how PCPs perceived remote consultations emerged: 1) remote consultations have an impact on the way physicians work, and 2) remote consultations have an impact on the service system and patients. The subthemes of the first main theme included the physicians’ new way of working, impacts on physicians’ well-being, and impacts on communication and physician competences. The subthemes for the second main theme were the importance of smoothness of services for the patients, patient suitability, and technical liabilities. Conclusion Remote consultations provide PCPs with a new way of working that could improve work-life balance. However, it is important to maintain sufficient clinical competence through versatile work. Digital consultations can make contacting healthcare smoother and easier for patients if the patient selection is performed carefully. Online chat seems suitable for singular contacts and simple issues, but remote consultations could be used to sustain continuity of care.

Performance trend of the family physician referral system before and during the COVID-19 pandemic: a study in northern Iran

BackgroundConsidering the challenges of the referral system in the family physician program and the impact of COVID-19 pandemic on the performance of the relevant ministry’s programs, it is necessary to assess the performance of the referral system. This study was conducted with the aim of investigating the performance of the family physician referral system before and during COVID-19 in Golestan province.MethodsThe present repeated cross-sectional study was conducted on secondary data Recorded of 786,603 cases referred and cared by family physicians (including information on physicians’ and midwives’ visits, percentage of prescriptions and other information) in Golestan province from 2017 to 2022 in a census and retrospective manner. Data were collected using the reference ratio checklist and analyzed with SPSS 23 software at a significance level of less than 0.05.ResultsReferral to 10 types of medical specialties and 10 indicators of family physicians referral before and during COVID-19 were investigated. The highest and lowest percentages of referrals by family physicians were belonged to the surgical (17.6%) and infectious (2%) specialists before COVID-19, and internal medicine (15.07%) and urology (3%) specialists during COVID-19, respectively. Referral due to physician’s diagnosis increased by 19.3% compared to before Covid-19, target group increased by 0.86%, care decreased by 2.69% and reverse referral decreased by 36.1%. The amount of population covered by rural insurance, the amount of visits to midwives, the percentage of electronic appointments in the post-Covid-19 years have changed significantly compared to before.it (P-Value < 0.05).ConclusionThe present study showed that the COVID-19 pandemic had a significant impact on family physician referral indicators, such as the process of referral to specialists, drug prescriptions, insurance coverage, one-time service population, and patient care, which can be used to eliminate the weaknesses and Strengthening the strengths of the programs being implemented in the face of possible pandemics is very useful and effective and can be used in the country. Finally, the results obtained from this research provide evidence to discuss the importance of the family physicians care and referral system in the face of special conditions for quality control in health policies.

Physician Follow-Up of Pediatric and Young Adult Emergency Department Visits for Substance Use in Ontario, Canada

PurposeTo study the proportion and predictors of outpatient physician follow-up within 60 days of substance-related emergency department (ED) visits for Ontario youth. MethodsWe examined administrative data on substance-related ED visits before and during the COVID-19 pandemic among youths aged 10–24 years in Ontario, Canada. Substance-related visits were identified using International Classification of Diseases-10-CA codes. We described demographic characteristics, receipt of mental health services in the year before the ED visit, disposition from the ED, and follow-up services within 60 days of the ED visit. ResultsBetween April 1, 2017, and May 31, 2021, 64,236 youth had at least one ED visit for substance use. Visits for alcohol were the most common (49%), followed by cannabis (32.3%). ED visits for all substances were more prevalent during the pandemic than prepandemic, except visits for alcohol. The receipt of follow-up physician care for substance use was low (33.2% prepandemic) but increased during the pandemic (41.7%; adjusted odds ratio 1.34, 95% CI 1.28, 1.39) and varied between substances. Mental health service history in the year before the substance-related ED visit had the strongest association with receipt of follow-up physician care within 60 days (adjusted odds ratio 6.86, 95% CI 6.57, 7.17). DiscussionYouth frequently do not receive physician follow-ups within two months of the substance-related ED visit, although higher follow-up proportions were seen during the pandemic after the implementation of virtual care. Further research is required to understand why follow-up is low and to examine interventions that can increase connection to care.

Homecare amyotrophic lateral sclerosis (ALS): A multidisciplinary, home-based model of care for patients with ALS and their caregivers.

Multidisciplinary care for patients with amyotrophic lateral sclerosis (ALS) is recommended in international guidelines, but reaches its limits when immobility increases. This pilot project addresses this gap by delivering home-based, specialized, multiprofessional support to ALS patients who are not able to attend outpatient care. The study assessed the feasibility of this model of care and the satisfaction of both patients and caregivers. This was a longitudinal cohort study of patients with ALS and their caregivers in the surroundings of Munich, Germany. Patients were regularly visited at home by a multiprofessional team (neurologists/palliative care physicians, nurse, social worker, chaplain). A total of 94 patients with ALS were included in the homecare project and 88 patients and 74 caregivers were enrolled in the accompanying study. The mean care duration was 221 days, enabling 61% of the 49 deceased patients to die at home. Notably, 20% of patients chose a way to hasten death. Patient satisfaction (ICECAP Supportive Care Measure [SCM]: 23.7/28, CollaboRATE: 10.6/12) and caregiver perception of the end-of-life phase (Caregiver Evaluation of the Quality of End-Of-Life Care [CEQUEL]: 24.9/26) were high. This pilot project successfully implemented specialized, home-based multidisciplinary care for ALS patients and caregivers, demonstrating both feasibility and high satisfaction. The program enabled a large proportion of patients to remain in their homes, reducing the need for hospital care. The multiprofessional approach, including neuropalliative, psychosocial and spiritual support provided comprehensive care that addressed needs of patients and caregivers. Further research is warranted to explore cost-effectiveness.

Physician and informal care use explained by the Pediatric Quality of Life Inventory (PedsQL) in children with suspected genetic disorders.

To examine associations between Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and PedsQL Infant Scales with formal health care resource utilization (HCRU) and informal caregiver burden. We studied a pediatric cohort of 837 patients (median age: 8.4 years) with suspected genetic disorders enrolled January 2019 through July 2021 in the NYCKidSeq program for diagnostic sequencing. Using linked ~ nine-month longitudinal survey and physician claims data collected through May 2022, we modeled the association between baseline PedsQL scores and post-baseline HCRU (median follow-up: 21.1 months) and informal care. We also assessed the longitudinal change in PedsQL scores with physician services using linear mixed-effects models. Lower PedsQL total and physical health scores were independently associated with increases in 18-month physician services, encounters, and weekly informal care. Comparing low vs. median total scores, increases were 10.6 services (95% CI: 1.0-24.6), 3.3 encounters (95% CI: 0.5-6.8), and $668 (95% CI: $350-965), respectively. For the psychosocial domain, higher scores were associated with decreased informal care. Based on adjusted linear mixed-effects modeling, every additional ten physician services was associated with diminished improvement in longitudinal PedsQL total score trajectories by 1.1 point (95% confidence interval: 0.6-1.6) on average. Similar trends were observed in the physical and psychosocial domains. PedsQL scores were independently associated with higher utilization of physician services and informal care. Moreover, longitudinal trajectories of PedsQL scores became less favorable with increased physician services. Adding PedsQL survey instruments to conventional measures for improved risk stratification should be evaluated in further research.

Household Health Care Payments Under Rate Setting, Spending Growth Target, and Single-Payer Policies

Households have high burden of health care payments. Alternative financing approaches could reduce this burden for some households. To estimate the distribution of household health care payments across income under health care reform policies. Cross-sectional study with microsimulation used nationally representative data of the US population in 2030. Civilian, noninstitutionalized population from the 2022 Current Population Survey linked to expenditures from the 2018 and 2019 Medical Expenditure Panel Survey and 2022 National Health Expenditure Accounts were included. Rate regulation of hospital, physician, and other health care professional payments equal to the all-payer mean in the status quo, spending growth target at 4% annual per capita growth, and single-payer health care financed through taxes. Household health care payments (out-of-pocket expenses, premiums, and taxes) as a share of compensation. The synthetic population contained 154 456 records representing 339.5 million individuals, with 51% female, 7% Asian, 14% Black, 18% Hispanic White, 56% non-Hispanic White, and 5% other races and ethnicities (American Indian or Alaskan Native only; Native Hawaiian or other Pacific Islander only; and 2 or more races). In the status quo, mean household health care payments as a share of compensation was 24% to 27% (standard error [SE], 0.2%-1.2%) across income groups (median [IQR] 22% [4%-52%] below 139% of the federal poverty level [FPL]; 21% [4%-34%] for households above 1000% FPL [11% of the population]). Under rate setting, mean (SE) payments by households above 1000% FPL increased to 29% (0.6%) (median [IQR], 22% [6%-35%]) and decreased to 23% to 25% for other income groups. Under the spending growth target, mean (SE) payments decreased from 23% to 26% (SE, 0.2%-1.2%) across income groups. Under the single-payer system, mean (SE) payments declined to 15% (0.7%) (median [IQR], 4% [0%-30%]) for those below 139% FPL and increased to 31% (0.6%) (median [IQR], 23% [3%-39%]) for those above 1000% FPL. Uninsurance fell from 9% to 6% under rate setting due to improved Medicaid access, and to zero under the single-payer system. Single-payer financing based on the current federal income tax schedule and a payroll tax could substantially increase progressivity of household payments by income. Rate setting led to slight increases in payments by higher-income households, who financed higher payment rates in Medicare and Medicaid. Spending growth targets reduced payments slightly for all households.

Electronic physician notification to facilitate the recognition and management of severe aortic stenosis: Rationale, design, and methods of the randomized controlled DETECT AS trial

BackgroundSymptomatic severe aortic stenosis causes substantial morbidity and mortality when left untreated, yet recent data suggest its undertreatment. ObjectiveTo evaluate the efficacy of electronic physician notification to facilitate the guideline-directed management of patients with severe aortic stenosis. HypothesisWe hypothesize that patients with severe aortic stenosis who are in the care of physicians who receive the notification are more likely to undergo aortic valve replacement within 1-year. Methods/DesignThe Electronic Physician Notification to Facilitate the Recognition and Management of Severe Aortic Stenosis (DETECT AS) trial is a randomized controlled trial and quality improvement initiative designed to evaluate the efficacy of electronic provider notification versus usual clinical care in the management of patients with severe aortic stenosis. Providers ordering an echocardiogram with findings potentially indicative of severe aortic stenosis, defined by an aortic valve area ≤1.0 cm2, are randomized in a 1:1 fashion to receive electronic notification (intervention) or usual care. Providers in the notification arm are sent a notification within the electronic health record inbox outlining customized guideline recommendations for the management of patients with severe aortic stenosis based on the 2020 ACC/AHA Clinical Practice Guidelines for Valvular Heart Diseases for the index and all subsequent echocardiograms. Providers in the control arm receive no notification. Randomization continues until 940 patients have been enrolled. SettingMulti-centered, academic health system OutcomesThe primary endpoint is the proportion of patients with severe AS receiving an aortic valve replacement within 1-year of the index echocardiogram. Secondary endpoints include mortality, heart failure hospitalization, transthoracic echocardiogram utilization/surveillance, aortic stenosis billing code diagnosis, and cardiology/Heart Valve Team referral. ConclusionThe DETECT AS trial will provide insight into whether electronic notification of providers on the presence of severe aortic stenosis and associated clinical guideline recommendations will facilitate recognition and guideline-directed management of severe aortic stenosis. Trial RegistrationClinicalTrials.gov, NCT05230225, https://clinicaltrials.gov/ct2/show/NCT05230225

Physicians’ Anxiety Post-COVID Pandemic: A Cross-Sectional Study

The psychological burden of physicians has been the focus of many researchers since the 1950s, and some papers have found a high prevalence of anxiety and depressive disorders among medical staff. Recent studies have shown that the coronavirus pandemic didn’t go easy on healthcare workers. The fact that it has been three years since the outbreak, has motivated our study. Which aims to evaluate the intensity of anxiety among medical personnel and the risk factors that could be incriminated post-COVID pandemic and if the level of anxiety is back to normal. This is a cross-sectional study, carried out with a survey split into 2 parts sociodemographic and work-related data, and the French version of the Hamilton anxiety scale, Statistical analysis was performed using Jamovi et Microsoft Excel. About half of the 116 physicians in our study had no anxiety (55.2%), while 21.6% had mild anxiety, 10.3% had moderate anxiety, and 12.9% had severe anxiety. The identified risk factors for anxiety were female gender, personal and family history of anxiety disorder, doing night shifts, and being a general practitioner. The anxiety rate of physicians is back to normal post-COVID pandemic. But we shouldn’t stop there. The mental health status of medical personnel depends on several of the factors listed above. Determining them would imply a call for the implementation of preventive measures for anxiety and depressive disorders among physicians. Because taking care of physicians is taking care of patients.

Multidrug stewardship and adherence to guidelines in >200,000 direct-to-consumer Telemedicine encounters.

The quality of care and safety for Telemedicine-discharged patients with suspected respiratory infections are closely related to low rates of prescriptions of unjustified and high-risk medications. This retrospective study aimed to assess adherence to the current COVID-19 guidelines in direct-to-consumer telemedicine encounters at a large center using multidrug stewardship protocols. A quarterly electronic survey utilizing medical records of individual physician care assessed various quality indicators. Physicians received ongoing adaptive feedback based on personal metrics, with Telemedicine Center recommendations derived from the 2020 Infectious Diseases Society of America guidelines. The study included all consecutive adults with new respiratory symptoms in the last 14 days who sought spontaneous Telemedicine consultations between March 2020 and August 2021. This study analyzed patients with suspected or confirmed COVID-19 and other airway infections. Of the 221,128 evaluated patients, 42,042 (19%) had confirmed COVID-19; 104,021 (47%) were suspected to have COVID-19; and, 75,065 (33%) had other diagnoses. Patients with suspected or confirmed COVID-19 had a mean (+DP) age of 35±12 years. A total of 125,107 (85.65%) patients were managed at home, 2,552 (1.74%) were referred for non-urgent in-office reassessment, and 17,185 (11.7%) were referred to the emergency department for whom there was no further treatment recommendation. The antibiotic rate in confirmed or suspected COVID-19 cases was 0.46%/0.65% and that for non-evidence-based prescriptions was 0.01%/0.005%. Guideline training and Telemedicine consultation feedback may lead to lower antibiotic and antimicrobial prescriptions in suspected and confirmed COVID-19 cases. Multidrug stewardship protocols may improve guideline adherence and reinforce the quality of care and safety in Telemedicine encounters.