Care Time Research Articles

Quality of care for postpartum hemorrhage: A direct observation study in referral hospitals in Kenya.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Kenya. The aim of this study was to measure quality and timeliness of care for PPH in a sample of deliveries in referral hospitals in Kenya. We conducted direct observations of 907 vaginal deliveries in three Kenyan hospitals from October 2018 through February 2019, observing the care women received from admission for labor and delivery through hospital discharge. We identified cases of "suspected PPH", defined as cases in which providers indicated suspicion of and/or took an action to manage abnormal bleeding. We measured adherence to World Health Organization and Kenyan guidelines for PPH risk assessment, prevention, identification, and management and the timeliness of care in each domain. The rate of suspected PPH among the observed vaginal deliveries was 9% (95% Confidence Interval: 7% - 11%). Health care providers followed all guidelines for PPH risk assessment in 7% (5% - 10%) of observed deliveries and all guidelines for PPH prevention in 4% (3% - 6%) of observed deliveries. Lowest adherence was observed for taking vital signs and for timely administration of a prophylactic uterotonic. Providers did not follow guidelines for postpartum monitoring in any of the observed deliveries. When suspected PPH occurred, providers performed all recommended actions in 23% (6% - 40%) of cases. Many of the critical actions for suspected PPH were performed in a timely manner, but, in some cases, substantial delays were observed. In conclusion, we found significant gaps in the quality of risk assessment, prevention, identification, and management of PPH after vaginal deliveries in referral hospitals in Kenya. Efforts to reduce maternal morbidity and mortality from PPH should emphasize improvements in the quality of care, with a particular focus on postpartum monitoring and timely emergency response.

Abstract PD1-05: Racial/Ethnic Segregation and Inequities in Metastatic Breast Cancer Treatment Initiation and Overall Survival

Abstract Background While racial/ethnic segregation, a form of structural racism, has been linked to health inequities, there is limited information regarding segregation and its potential impact on breast cancer care and outcomes. Here we assessed whether and to what extent racial/ethnic segregation is associated with timeliness of care and real-world overall survival (rwOS) in patients diagnosed with metastatic breast cancer (mBC). Methods This retrospective study used the nationwide Flatiron Health electronic health record-derived de-identified database. The cohort included community oncology patients (≥ 18 years) diagnosed with mBC between January 2011 and April 2022. Census tract data from the American Community Survey (2015-2019) was used to characterize neighborhoods based on the most recent recorded patient address. Segregation was defined as predominant race/ethnicity (e.g., tracts whose population was ≥ 50% non-Latinx Black were labeled as predominantly Black neighborhoods). Timeliness of care was defined as biomarker (estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2) testing within 30 days and systemic treatment initiation within 60 days of metastatic diagnosis (evaluated using Χ2 tests). We estimated Cox proportional hazard models adjusted for age and sex to examine rwOS (patients were followed from diagnosis to death or last recorded activity). Results Among 18,884 patients diagnosed with mBC (median age: 65 years), 71.0% lived in predominantly White neighborhoods, 7.5% in Black neighborhoods, and 8.7% in Latinx neighborhoods. Compared with patients residing in predominantly White neighborhoods, patients in Black and Latinx neighborhoods were more likely to be diagnosed with de novo mBC (30.7% vs. 34.8% and 33.5%, respectively) and have Medicaid (7.6% vs. 15.8% and 15.3%). Fewer patients in predominantly Black (74.4%) and Latinx (69.9%) neighborhoods received timely biomarker testing compared to patients in White (77.7%) neighborhoods (p <.01). Similarly, fewer patients in predominantly Black (73.5%) and Latinx (72.6%) neighborhoods had timely treatment initiation compared to patients in White (79.6%) neighborhoods (p <.01). Patients in Black neighborhoods (HR 1.24, 95% CI 1.16-1.33) had worse rwOS than patients in White (ref.) and Latinx neighborhoods (HR 0.90, 95% CI 0.83-0.97). Conclusions Our results suggest that racial/ethnic segregation is associated with inequities in breast cancer care and outcomes, where patients in predominantly Black and Latinx neighborhoods are less likely to receive timely care than those in White neighborhoods. Living in predominantly Black neighborhoods was also associated with reduced survival. Therefore, efforts to reduce cancer inequities should target higher-order structural factors associated with worse cancer care and outcomes, including segregation and other forms of structural racism. Citation Format: Jenny S. Guadamuz, Gregory S. Calip, Alemseged A. Asfaw, Xiaoliang Wang, Harlan Pittell, Maneet Kaur, Amy E. Pierre, Cleo A. Ryals. Racial/Ethnic Segregation and Inequities in Metastatic Breast Cancer Treatment Initiation and Overall Survival [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-05.

European Cancer Summit 2022 Submission for Health Systems and Treatment Optimisation NetworkThe All.Can Cancer Efficiency Metrics Study: A collaborative policy research project to identify a standard set of metrics to measure cancer care ‘efficiency’: REPORT LINK: https://www.all-can.org/wp-content/uploads/2022/06/Final_The-Al.Can-Efficiency-Metrics-Study.pdf

BackgroundInefficient care is a leading factor in poorer outcomes for patients. According to the OECD, one-fifth (20%) of healthcare expenditure either does not improve people’s health or could worsen their outcomes [1]. In addition, the World Health Organisation estimates that 40% of health spending is wasted through inefficiency [2]. These issues undermine the principles of efficient, person-centered care [3]All.Can International defines ‘efficiency’ in cancer care as: “Care that delivers the best possible health outcomes using the human, financial, infrastructural and technological resources available, with a focus on what really matters to patients and society.”The All.Can “Cancer Efficiency Metrics Study”, presents an evidence-based suite of cancer care efficiency metrics identified through a robust evidence review and stakeholder interviews. MethodsA mixed methodology was used, involving a systematic search of medical databases and cancer registries, yielded 126 publications and information from 16 registries, and information from interviews with 20 stakeholders from across the cancer care continuum. ResultsThe research identified 13 cancer metric categories, 24 cancer metric themes and 137 individual cancer metrics. Ultimately, from examining what metrics were specifically referred to across all the data sources, a core set of 8 metrics were identified, as follows: [Display omitted] Importantly, there were only three metric themes where the research, registries and interviews consistently mapped:•Timeliness of care•Quality of care; and•Financial toxicity ConclusionThe report offers a set of evidence-based metrics that stakeholders across the cancer care continuum can use to consistently assess, benchmark and improve efficiency in patient-centred cancer care. The report also identified opportunities to progress this foundational research, including:•Validating these metrics with patients’, families and carers•Utilising these metrics, to establish a baseline for progressive improvement of efficiency in real-world settings•Expanding the research, to broaden data-driven insights from across the cancer care continuum.

Abstract P1-06-04: IMPACTS OF TREATMENT DELAY ON BREAST CANCER MORTALITY AND BENEFIT OF TIMELY CARE IN BLACK AND NON-BLACK WOMEN

Abstract BACKGROUND: The impact of treatment delays on cancer outcomes has been well documented, but few published studies explicitly attempt to identify subgroups which would benefit the most from potential interventions improving timeliness of care. Using the state of North Carolina and breast cancer as an example, we sought to quantify race-specific associations between frontline treatment delay and breast cancer mortality, and estimate the potential impact of improvements in timeliness by racial sub-group. METHODS: We conducted a retrospective cohort study, utilizing multipayer insurance claims linked to cancer registry data from the Cancer Information and Population Health Resource, of females diagnosed with stage I-III breast cancer from 2004 to 2014. Our exposure of interest was treatment delay, defined as initial cancer directed therapy received ≥ 60 days after diagnosis. Our outcome was death certificate identified breast cancer mortality within 5-years of follow-up. To quantify the association between treatment delay and mortality we estimated hazard ratios (HR) and 95% confidence limits (CL) where non-breast cancer deaths were treated as competing events. We then simulated the effect of treating all patients within 60 days using inverse probability of treatment weighting (IPTW), and estimated the potential impact by comparing the simulated data with observed data. Models were adjusted for age and stage at diagnosis, tumor grade, hormone receptor status, and modality of first treatment. Models were stratified by race, dichotomized as Black or non-Black, and geographic subregion for evaluation. RESULTS: Our analytic cohort comprised 21,200 patients, of whom 19% were Black. Treatment delays >60 days were twice as frequent among Black compared with non-Black patients (13.5% vs. 6.5%). We found a positive association between treatment delay and breast cancer mortality in the overall cohort (HR=1.3; CL: 1.1, 1.6). The association differed between Black (HR=1.4; CL: 1.1, 1.8) and Non-Black (HR=1.2; CL: 0.9, 1.6) patient subgroups. For both racial groups, the strength of the relationship between treatment delay and mortality varied across geographic subregions. The estimated potential improvement in 5-year cumulative breast cancer mortality from delivering timely care to all patients differed in magnitude across sub-populations. The magnitude of potential improvement in breast cancer mortality at 5 years in the overall analytic cohort was 0.3% (5-year risk of breast cancer mortality in observed cohort: 7.2% vs 6.9% with simulated universal timely treatment). In the Black subcohort, the potential decrease in mortality for timely treatment was 1.0% (observed: 12.3% vs simulated: 11.4%), while in the non-Black population the potential decrease was 0.1% (observed: 6.1% vs simulated: 5.9%). CONCLUSIONS: The magnitude of association between delayed treatment of stage I-III breast cancer and breast cancer mortality differed between Black and non-Black patients, highlighting that interventions to avert treatment delays may have a meaningful impact for this group. Further research is needed to identify factors underlying this difference, which may include a direct effect of differences in timeliness, or downstream differences in the intensity and quality of cancer care beyond the 60-day landmark for delayed patients. Our findings suggest that comprehensive intervention at the state level to improve the timeliness of breast cancer treatment could potentially reduce breast cancer mortality, and that targeting such intervention to patient groups with larger projected benefit, such as Black patients, may be a more efficient use of resources. We have illustrated how a counterfactual approach may be useful in identifying subgroups where focused intervention efforts may yield greater improvements in outcomes. Citation Format: Bradford Jackson, Stephanie Wheeler, Juan Yanguela, Matthew LeBlanc, Tzy-Mey Kuo, Christopher Baggett, Katherine Reeder-Hayes. IMPACTS OF TREATMENT DELAY ON BREAST CANCER MORTALITY AND BENEFIT OF TIMELY CARE IN BLACK AND NON-BLACK WOMEN [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-06-04.

Impact of interhospital transfer on emergency department timeliness of care and in-hospital outcomes of adult non-trauma patients

BackgroundPatients who present to the emergency department (ED) from interhospital transfer (IHT) and non-IHT are known to have differences in various clinical outcomes including mortality. The ED timeliness of care is an effective indicator of the quality of ED care and operational efficiency. The impact of IHT on ED timeliness of care remains unclear. We evaluated the association between IHT and ED timeliness of care or in-hospital outcomes in adult non-trauma patients. MethodsData of consecutive hospital admission of adult non-trauma patients who visited the ED of a medical center from January 2018 to Jun 2020 were retrospectively analyzed. The patients were divided into IHT and non-IHT cohorts. Various data were recorded. The ED length of stay (LOS) was measured as the outcome of ED timeliness of care, while hospital LOS and in-hospital death were measured as the in-hospital outcomes. Multiple regression analyses were performed using unmatched and propensity-matched cohorts. In the later analyses, both groups were propensity matched for sex, age, and other covariates that showed significant differences between two groups to achieve a 1:4 balanced cohort. ResultsData on 1856 IHT patients and 16295 non-IHT patients were analyzed. IHT was associated with a shorter ED LOS, longer hospital LOS, and higher odds of in-hospital death compared with non-IHT in unmatched and propensity-matched analyses. The shorter ED LOS was due to the slightly longer interval of arrival to ED physicians (∼1 min) and considerably shorter intervals of ED physicians to decision (∼120 min) and decision to departure (∼105 min). Risk stratification revealed that IHT was associated with a shorter ED LOS in patients with all levels (1–5) of Taiwan Triage and Acuity Scale (TTAS) and associated with longer hospital LOS and higher odds of in-hospital death in patients with TTAS level ≥3. ConclusionsIHT was associated with a shorter ED LOS, longer hospital LOS, and higher odds of in-hospital death in adult non-trauma patients compared with non-IHT. The expedited ED timeliness of care in the IHT cohort was due to considerably shorter intervals of both ED physicians to decision and decision to disposition.

The August 2020 COVID-19 outbreak in Aotearoa, New Zealand: Delayed contact tracing for Pacific people contributes to widening health disparities

BackgroundAfter COVID-19 arrived in New Zealand, a national system was developed to improve the efficiency of contact tracing. The first outbreak was followed by a period of ‘COVID-19 elimination’, until a community outbreak occurred in August 2020. We describe the characteristics of cases and their contacts during this outbreak, focused on the results of contact tracing. MethodsCOVID-19 case data from the national surveillance database were linked to contacts from the national contact tracing database. Demographic and clinical characteristics of cases, number of contacts, and timeliness of contact tracing were analysed by ethnicity. FindingsMost of the 179 cases were Pacific people (59%) or Māori (25%), living in areas of high socioeconomic deprivation, who had higher rates of comorbidity and accounted for almost all (21/22) hospitalisations, all 8 ICU admissions and all 3 deaths. Only 6% belonged to the European majority ethnic group. Of 2,528 registered contacts, 46% were Pacific, 14% Māori and 19% European. Only contacts that were reached were registered. Overall, 41% of contacts were reached within 4 days of onset of disease of the case, which was significantly lower for Pacific (31%) than for other ethnic groups. InterpretationOur findings confirm the greater health burden that ethnic minorities face from COVID-19. The significant delay in the timeliness of care for Pacific people shows that the public health response was inequitable for those at highest risk. Tailored public health responses and better registration of marginalised groups are necessary to provide better access to services and to improve insights for optimal future outbreak management.

Discordance between clinical and pathologic staging and the timeliness of care of non-small cell lung cancer patients diagnosed with operable tumors.

This study was performed to evaluate concordance between clinical and pathologic staging of non-small cell lung cancer (NSCLC) in our hospital network. We retrospectively reviewed records of 417 patients with NSCLC who received curative surgery and whose pathology was evaluated in our hospital between 2016 and 2021. Cytology, tissue pathology, and associated clinical, surgical, and imaging information were retrieved from hospital digital records. The cohort included 214 female and 203 male patients aged 20.6-85.8 years. Median times among staging computed tomography and surgery (105 days [interquartile range (IQR) 77.0-143.0]), positron emission tomography and surgery (78.5 days [IQR 56.0-109.0]), and endobronchial ultrasound-guided transbronchial needle aspiration and surgery (59 days [IQR 42-94]) indicated that Australian guidelines of <42 days between original referral and commencement of treatment were not being met in the majority of cases. Discordance between clinical TNM (cTNM) and pathologic TNM staging was 25.9%, including 18.4% cases that were clinically understaged and two patients with undetected stage IVA disease. cTNM understaging was significantly associated with time between the final staging investigation and surgery (p=.023), pleural (p<.05) and vessel (p<.05) invasion, and diagnosis of high-grade adenocarcinoma (p=.001). Discordance between clinical and pathologic staging of NSCLC is associated with tumor histopathologic characteristics and treatment delays. Although tumor factors that lead to discordant staging cannot be controlled, reduced time to surgery may have resulted in better outcomes for some patients in this potentially curable lung cancer cohort.

Impact of merging two university hospitals on surgical outcome after esophagogastric and hepato-pancreato-biliary surgery: Results from a retrospective study

BackgroundDue to centralization and super-specialization in medicine, hospital mergers are increasingly common. Their effect on postoperative outcomes in highly specialized surgical departments is unclear. As quality metrics often worsen after major organizational changes, preservation of quality of care during an hospital merge is of the utmost importance. ObjectiveTo evaluate the effect of a merger of two Dutch university hospitals on quality of surgical care, volume, and timeliness of care. MethodsThe upper gastro-intestinal and hepato-biliary-pancreatic sections merged on the 27th of January 2020 and the 31th of May 2021 respectively. Outcomes of all adult surgical patients were compared six months before and six months after the merger. Short-term quality metrics, volume, and timeliness of care were assessed. ResultsOverall, a cohort of 631 patients were included of whom 195 were upper gastro-intestinal (97 prior to the merger, 98 after the merger) and 436 (223 prior to the merger, 213 after) hepato-biliary-pancreatic patients. There were no differences in mortality, readmission, number and severity of complications, volume, and timeliness of care six months post-merger as compared to before merger. ConclusionThis study shows that a hospital merger of two university hospitals can be performed without jeopardizing patient safety and while benefitting from centralization of highly specialized care and enhancement of medical research. Key messageThis study investigated the impact of a merger of two Dutch university hospitals on quality of care, timeliness of care, and volume. It showed no deterioration in the evaluated short-term quality metrics, volume or timeliness for upper GI and HPB surgery, suggesting that a hospital merger of two university hospitals can be performed safely, while benefitting from centralization of highly specialized care and enhancement of medical research.

Experience and Attitudes Toward Telehealth in Student-Run Free Clinics (SRFC).

Telehealth services expanded during the coronavirus disease 2019 (COVID-19) pandemic. Student-run free clinics (SRFC) deliver important health care services to underserved populations, who may face barriers to telehealth use. This study characterizes telehealth usage, experiences, and attitudes among individuals working in SRFCs. In November 2021, a survey adapted from the COVID-19 Healthcare Coalition Telehealth Impact Physician Survey was sent to all registrants who identified themselves as students at the 2020 Society of Student-Run Free Clinics Annual Conference. Thirty-eight individuals of 576 registrants (7%) representing 21 of 88 (24%) SRFCs completed the survey. Twenty-one (58%) individuals reported using telehealth in their clinic. Those that did not cited lack of infrastructure as a barrier (eg, broadband, Internet challenges, technology investments), were more likely to serve homeless (P = .01), and less likely to serve non-English speaking populations (P = .02). There were increases in telehealth and decreases in in-person visits after March 11, 2020 though changes did not reach statistical significance. At least 15 (68%) wanted to continue chronic disease management, preventative care, and mental/behavioral health via telehealth after COVID-19. Most felt that telehealth was easy to use and improved the health, safety, and timeliness of care of patients, but not work satisfaction or access to care. Difficulty accessing physical devices, Internet, and data was the most-cited barrier to maintaining and accessing telehealth. Nearly all participants cited significant benefits and barriers to telehealth that impacted perceived access to care and sustainability. SRFCs' experiences may be modulated by their underserved populations and role in student education. Addressing barriers, particularly patient- and clinic-level technology challenges, could work to improve inequities in telehealth uptake.

A service evaluation of the assessment process in a Step4 Psychological Therapies Service

Purpose This study aims to improve the efficiency of the assessment process within a Step4 Psychological Therapies Service by identifying factors related to assessment non-attendance and service suitability for referred clients. Design/methodology/approach Referral and assessment information was accessed between October 2019 and March 2020 from Step4 routine service data, electronic client records where necessary and Step4 staff self-report questionnaires. Findings All clients offered an assessment during this time attended. Findings indicated several factors could influence service suitability in meeting client need. These included individual differences such as readiness to change, which was not necessarily identified at referral or prior to assessment, and potential systemic factors, such as the opt-in procedure, which possibly impeded access. Though the necessity for assessment in clarifying client needs and treatment was indicated, an assessment (from referral to assessment appointment) that led to discharge could take an excess of one working day of service time, associated with considerable opportunity cost to other clients awaiting assessment. Recommendations are made for improving assessment efficiency. Originality/value With a high prevalence of poor mental health in the UK, efforts must be made to identify and reduce additional demand upon service time and resources within mental health services to effectively meet people’s needs. Recommendations to improve assessment process efficiency include the use of a standardised referral form, offer of follow-up support procedures, increased client involvement, a streamlined opt-in battery and ongoing monitoring to ensure shared practice between clinicians. These are transferable to other mental health services, with implications for subsequent quality and timeliness of care.

Efficacy of controlvit as a complementary strategy in reducing hospitalizations in patients with heart failure. Randomized clinical trial

Abstract Introduction In patients with heart failure, the main cause of hospital admissions is due to episodes of decompensation, which are associated with an increase in the costs and resources needed for care; they have a negative impact on the quality of life and prognosis of the disease. Therefore, it is necessary to design, evaluate and implement alternatives to achieve efficient follow-up and monitoring, improving adherence to treatment and helping identify decompensation episodes that facilitate their early treatment, so new hospital admissions can be avoided. For this reason, the use of information and communication technologies (apps) is emerging as an excellent strategy for the possibility of improving coverage, real-time monitoring and timeliness of care. ControlVit® is an electronic application that allows permanent, real-time monitoring of biomedical measurements for early detection of complications. Objective To determine the efficacy of ControlVit® as a complementary strategy in reducing hospital admissions in patients in a heart failure program. Methodology A randomized, placebo-controlled, open-label clinical trial was conducted, (n=140), included patients with heart failure under controlled clinical follow-up in a structured heart failure program, into NYHA FC II–IV, capable of handling smartphones and with permanent internet connectivity. All patients were provided with educational elements, a scale and a blood pressure monitor to enter clinical data and a symptom questionnaire necessary for follow-up. The patients were randomized to 2 groups: intervention: use of ControlVit® vs. placebo, with a 6-month follow-up. The primary outcome was the difference in readmissions for heart failure between the 2 groups. Patients on the waiting list for heart transplantation or use of ventricular assist devices were excluded. All participants signed informed consent and the protocol was approved by the institutional ethics committee. Results A total of 140 patients were included in the study (intervention = 71, placebo = 69), with an average age of 66 years, 71% were men, the main etiology of heart failure was ischemic (60%), the main comorbidities were arterial hypertension (44%), dyslipidemia (42%), hypothyroidism (38%), chronic kidney disease (38%), and diabetes mellitus (27%). During follow-up, there were 6 deaths (3 in each group) and 17 readmissions (3 in the intervention group and 14 in the control group). After adjustment for comorbidities, HR 0.72 CI95 (0.52; 0.92), p=0.0325 was found. Conclusion In patients with heart failure, ControlVit® is a useful and complementary tool for follow-up, which reduces hospital admissions due to episodes of decompensation. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): German Saldarriega award.Javeriana University

Does hospital location matter? Association of neighborhood socioeconomic disadvantage with hospital quality in US metropolitan settings.

An aspect of a hospital's location, such as its degree of socioeconomic disadvantage, could potentially affect quality ratings of the hospital; yet, few studies have granularly explored this relationship in United States (US) metropolitan areas characterized by a wide breadth of socioeconomic disparities across neighborhoods. An understanding of the effect of neighborhood socioeconomic disadvantage on hospital quality of care is informative for targeting resources in poor neighborhoods. We assessed the association of neighborhood socioeconomic disadvantage with hospital quality of care across several areas of quality (including mortality, readmission, safety, patient experience, effectiveness of care, summary and overall star rating) in US metropolitan areas. Hospitals in the most disadvantaged neighborhoods, compared to hospitals in the least disadvantaged neighborhoods, had worse mortality scores, readmission scores, safety of care scores, patient experience of care scores, effectiveness of care scores, summary scores and overall star rating. Timeliness of care and efficient use of imaging scores were not strongly associated with neighborhood socioeconomic disadvantage; although, future studies are needed to validate this finding. Policymakers could target innovative strategies for improving neighborhood socioeconomic conditions in more disadvantaged areas, as this may improve hospital quality.

Teledermatology in Rural, Underserved, and Isolated Environments: A Review.

Purpose of ReviewSummarize the current evidence for teledermatology in rural, underserved, and isolated environments including its use during the current COVID-19 pandemic.Recent FindingsTeledermatology is a reliable and cost-effective tool that can reduce face-to-face visits and improve the timeliness of care for medically underserved populations. Recent studies have shown many additional benefits of teledermatology, including improving patients’ health outcomes and increasing local providers’ knowledge of dermatologic conditions. Despite these benefits, many low-income and rural populations lack access to digital technology and high-speed internet, limiting the reach of telemedical services.SummaryOverall, barriers in access to care are unique across the globe, and thus teledermatology interventions should address and adapt to the needs of the local patient population. Certain strategies, such as implementing simple, SF models, using standardized TD consult templets, and providing real-time information technology support could potentially mitigate disparities and improve the effectiveness of TD programs in underserved areas.

Efficacy of controlvit as a complementary strategy in reducing hospitalizations in patients with heart failure. Randomized clinical trial

Abstract Introduction In patients with heart failure, the main cause of hospital admissions is due to episodes of decompensation, which are associated with an increase in the costs and resources needed for care; they have a negative impact on the quality of life and prognosis of the disease. Therefore, it is necessary to design, evaluate and implement alternatives to achieve efficient follow-up and monitoring, improving adherence to treatment and helping identify decompensation episodes that facilitate their early treatment, so new hospital admissions can be avoided. For this reason, the use of information and communication technologies (apps) is emerging as an excellent strategy for the possibility of improving coverage, real-time monitoring and timeliness of care. ControlVit® is an electronic application that allows permanent, real-time monitoring of biomedical measurements for early detection of complications. Objective To determine the efficacy of ControlVit® as a complementary strategy in reducing hospital admissions in patients in a heart failure program. Methodology A randomized, placebo-controlled, open-label clinical trial was conducted, (n=140), included patients with heart failure under controlled clinical follow-up in a structured heart failure program, into NYHA FC II–IV, capable of handling smartphones and with permanent internet connectivity. All patients were provided with educational elements, a scale and a blood pressure monitor to enter clinical data and a symptom questionnaire necessary for follow-up. The patients were randomized to 2 groups: intervention: use of ControlVit® vs. placebo, with a 6-month follow-up. The primary outcome was the difference in readmissions for heart failure between the 2 groups. Patients on the waiting list for heart transplantation or use of ventricular assist devices were excluded. All participants signed informed consent and the protocol was approved by the institutional ethics committee. Results A total of 140 patients were included in the study (intervention = 71, placebo = 69), with an average age of 66 years, 71% were men, the main etiology of heart failure was ischemic (60%), the main comorbidities were arterial hypertension (44%), dyslipidemia (42%), hypothyroidism (38%), chronic kidney disease (38%), and diabetes mellitus (27%). During follow-up, there were 6 deaths (3 in each group) and 17 readmissions (3 in the intervention group and 14 in the control group). After adjustment for comorbidities, HR 0.72 CI95 (0.52; 0.92), p=0.0325 was found. Conclusion In patients with heart failure, ControlVit® is a useful and complementary tool for follow-up, which reduces hospital admissions due to episodes of decompensation. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): German Saldarriega award.Javeriana University

Evaluation of facilitators and barriers of timely breast cancer care in North Carolina (NC): A qualitative study.

134 Background: Early detection and timely treatment of breast cancer using multi-disciplinary therapies often contributes to a goal of curative intent along with improved overall outcomes. In prior studies, Black women compared to non-Black women are at a higher chance of treatment delay (&gt; 60 days) in NC. The care team factors that contribute to these treatment delays are unclear. Methods: This qualitative study utilized content analysis. The 30 participants included community stakeholders involved in breast cancer care delivery, including breast cancer clinicians and community resource providers. Participants were selected through purposive sampling. Three Area Health Education Centers (AHEC) regions (Northwest, Charlotte, and Area L) that represent the diversity of the state of NC were selected as sites for data collection. Each participant completed a one-time semi-structured interview which was audio-recorded and transcribed. Inductively derived codes were created from the previously established interview guide leading to the production of the codebook with each code conceptually defined. Transcripts were coded by 7 coders through the method of consensus coding leading to the identification of emergent themes. Code reports were generated from each code leading to the production of a narrative summary. Results: All participants identified perceived both facilitators and barriers to the timely initiation of breast cancer treatment. Barriers fell into several categories: geographical, financial, healthcare system related, and patient related (non-financial). Most barriers were perceived as more common among Black patients. Additionally, participants emphasized incidents of historical racism in medical care that limited Black patients from having trust in the healthcare system. Facilitators identified included: outreach through community partners, healthcare navigation, supportive healthcare providers, provision of social support services, transportation, integrative services, and raising the overall quality of cancer care. Conclusions: Despite the diversity of participants regarding region, years of employment, and role, stakeholders identified important common themes when reviewing the perceived facilitators and barriers of breast cancer care delivery. Perceived barriers were largely related to patients’ social determinants of health, and participants perceived that Black patients had more adverse social determinants impacting their care timeliness, highlighting that structural racism contributes to delayed cancer care delivery. Future initiatives aimed at improving the delivery of timely breast cancer care must focus on evaluating marginalized communities’ overall access to adequate care along with effective community engagement to build a higher level of trust from such patients and target the social determinants of health.

Effect of COVID 19 pandemic on time to care, use of ambulance, admission characteristics, demography, injury characteristics, management and outcome of Paediatric Orthopaedic trauma patients admitted to the trauma centre

Background: Lockdown imposed to limit the spread of COVID 19 may have had a significant effect on the time to care, demography, injury causation, injury characteristics, volume and nature of admission, management and outcome of paediatric orthopaedic trauma patients. Objective: To document the effect of lockdown on the time to care at KGMU, use of ambulance, volume and type of admissions, demography, injury causation, injury characteristics, management and outcome of paediatric orthopaedic trauma patients. Methods:. This record review compared age, sex, type of admission, mechanism of injury, injury characteristics, type of treatment, vehicle used for transport, and outcome among patients admitted in pre-lockdown, lockdown and post lockdown. Results: Lockdown was associated with decrease in the number of cases (p&lt;0.01), increase in the time since injury to reception (p&lt;0.040), a rise in the share of referred admission (p&lt;0.040), time since reception at KGMU, time to definitive care (p&lt;0.001), high energy falls (p&lt;0.001), injuries at home (p&lt;0.001), higher ISS (p&lt;0.001), non operative treatment (p=0.038) and greater use of ambulance (p=0.003). Conclusion: Lockdown resulted in a significant change in the causation and management of injury, significant delays in timeliness of care, reduction in the volume of admissions, an increase in injury severity and share of referral admissions.

Teledermatology to Facilitate Patient Care Transitions From Inpatient to Outpatient Dermatology: Mixed Methods Evaluation.

BackgroundBoth clinicians and patients have increasingly turned to telemedicine to improve care access, even in physical examination–dependent specialties such as dermatology. However, little is known about whether teledermatology supports effective and timely transitions from inpatient to outpatient care, which is a common care coordination gap.ObjectiveUsing mixed methods, this study sought to retrospectively evaluate how teledermatology affected clinic capacity, scheduling efficiency, and timeliness of follow-up care for patients transitioning from inpatient to outpatient dermatology care.MethodsPatient-level encounter scheduling data were used to compare the number and proportion of patients who were scheduled and received in-clinic or video dermatology follow-ups within 14 and 90 days after discharge across 3 phases: June to September 2019 (before teledermatology), June to September 2020 (early teledermatology), and February to May 2021 (sustained teledermatology). The time from discharge to scheduling and completion of patient follow-up visits for each care modality was also compared. Dermatology clinicians and schedulers were also interviewed between April and May 2021 to assess their perceptions of teledermatology for postdischarge patients.ResultsMore patients completed follow-up within 90 days after discharge during early (n=101) and sustained (n=100) teledermatology use than at baseline (n=74). Thus, the clinic’s capacity to provide follow-up to patients transitioning from inpatient increased from baseline by 36% in the early (101 from 74) and sustained (100 from 74) teledermatology periods. During early teledermatology use, 61.4% (62/101) of the follow-ups were conducted via video. This decreased significantly to 47% (47/100) in the following year, when COVID-19–related restrictions started to lift (P=.04), indicating more targeted but still substantial use. The proportion of patients who were followed up within the recommended 14 days after discharge did not differ significantly between video and in-clinic visits during the early (33/62, 53% vs 15/39, 38%; P=.15) or sustained (26/53, 60% vs 28/47, 49%; P=.29) teledermatology periods. Interviewees agreed that teledermatology would continue to be offered. Most considered postdischarge follow-up patients to be ideal candidates for teledermatology as they had undergone a recent in-person assessment and might have difficulty attending in-clinic visits because of competing health priorities. Some reported patients needing technological support. Ultimately, most agreed that the choice of follow-up care modality should be the patient’s own.ConclusionsTeledermatology could be an important tool for maintaining accessible, flexible, and convenient care for recently discharged patients needing follow-up care. Teledermatology increased clinic capacity, even during the pandemic, although the timeliness of care transitions did not improve. Ultimately, the care modality should be determined through communication with patients to incorporate their and their caregivers’ preferences.

Predictors of the relationship between the duration of cancer and care time with the supportive care needs of patients and the quality of life of their caregivers: a path analysis.

Breast cancer (BC) patients face various physical and psychological challenges. The mutual impacts of patients and caregivers on each other show the need for further supportive care from the community and family. This study aimed to identify the predictors of the direct and indirect relationships of the duration of cancer (CANCERT) and care time (CARET) with the supportive care needs (SCN) of the patients and the quality of life (QOL) of their family caregivers. This descriptive study included 150 patients and their caregivers in Iran. Data were collected using the Supportive Care Needs Survey-Short Form (SCNS-SF34), the Caregiver Quality of Life Index-Cancer (CQOLC) scale, and a socio-demographic checklist. The data were then analyzed in SPSS-24 and Lisrel-8.8 software using descriptive statistics and path analysis. The mean age of the patients and caregivers was 45.76 ± 10.44 and 43.46 ± 9.5, respectively. The majority of patients (96%) were in stages II and III of the disease. There was no statistically significant relationship between cancer stages with SCN of the patients and also caregivers' QOL (P > 0.05). Based on the test results, the CANCERT was positively correlated with the patients' care and support needs (SN) in total effect (β = 0.24). The patients' sexuality needs had the highest negative correlation with their CANCERT in the direct path (β = - 0.27) and had the highest negative correlation with psychological needs in the indirect path (β = - 0.174). The CARET (hours per day) had positive correlation with health systems and information needs in both the direct (β = 0.26) and indirect paths (β = 0.15). The highest positive correlation with physical needs was in the direct path (β = 0.34). The caregivers' QOL had a negative and direct relationship with the CANCERT (β = - 0.19), and there was a positive and direct relationship between CARET and the caregivers' QOL (β = 0.18). The correlations obtained from this study are not necessarily strong, yet they are important and should be noticed and tested in the future studies. The present findings reveal the need to provide comprehensive care, planning to provide supportive care, and counseling to both BC patients and their family caregivers, especially when the duration of the disease is prolonged.

Access to surgical care in Ethiopia: a cross-sectional retrospective data review

BackgroundAccess to emergency and essential surgical care is still unmet and accessibility is disproportionately inequitable in Ethiopia and other low-and middle-income countries. The aim of this study was to assess surgical care access in terms of capability, capacity, and timeliness of care in different levels of health care in Ethiopia.MethodsA cross-sectional study with retrospective data review was conducted in 172 health facilities from December 30, 2020 to June 10, 2021. Descriptive statistics such as median with interquartile range and proportion were computed using STATA Version 15 statistical software.ResultsWithin a 90-day interval of the study period, 69,717 major and minor surgeries, and 33,052 bellwether procedures were performed, and major surgeries accounted for 58% of the surgeries. About 1.6%, 23.56%, 25.34%, and 32.2% of both major and minor, and 3.1%, 12.8%, 27.6%, and 45.3% of bellwether procedures were performed in health center OR blocks, primary, general, and specialized hospitals, respectively. Private hospitals performed 17.33% of major and minor and 11.2% of bellwether procedures for the period. The average pre-admission waiting time for surgical patients in primary, general, and specialized hospitals was 9.68, 37.6, and 35.9 days, respectively, whereas, in private hospitals, the average pre-admission waiting time was 1.42 days. On average, surgical patients traveled 5 Hrs, 11 Hrs, 28.4 Hrs, and 21.3 Hrs to access surgical services in primary, general, specialized, and private hospitals, respectively. The surgical workforce to the population served ratio was 7.5, 1.15, and 1.31/100.000 population in primary, specialized and general hospitals, respectively.ConclusionMost surgical procedures were performed in specialized hospitals, indicating that there is a burden in these health facilities. The pre-admission waiting time for surgical patients was long in higher-level public hospitals. Surgical patients traveled a long distance to access surgical service in higher level hospitals. The ratio of surgical workforce per 100,000 population served was low in all levels of public health facilities in general, and in higher level hospitals in particular. Efforts should therefore be made to strengthen all levels of the health system and improve surgical care access in terms of capacity, capability, and timeliness in the country.

Racial and ethnic differences in patient ratings of colorectal and non-small-cell lung cancer care: A SEER-CAHPS study.

Although significant racial and ethnic disparities exist in colorectal and lung cancer treatment and survival, racial differences in patient-reported experience of care are not well understood. The purpose of this study was to examine differences in patient-reported ratings of colorectal and non-small-cell lung cancer care by race/ethnicity. Medicare beneficiaries with AJCC stage I-IV colorectal and non-small-cell lung cancer (2003-2013) who completed a Medicare Consumer Assessment of Healthcare Providers (CAHPS) survey within 5years of cancer diagnosis were identified in the linked SEER-CAHPS dataset. Scores were compared by race/ethnicity, defined as White, Black, or any other race/ethnicity. Of the 2,621 identified patients, 161 (6.1%) were Black, 2,279 (87.0%) White, and 181 (6.9%) any other race/ethnicity. Compared to White patients, Black patients were younger, had lower educational level, and had higher census tract poverty indicator (p < 0.001). Black patients rated their ability to get care quickly significantly lower than White patients (63.5 (SE 3.38) vs. 71.4 (SE 2.12), p < 0.01), as did patients of any other race/ethnicity (LS mean 66.2 (SE 2.89), p = 0.02). Patients of any other race/ethnicity reported their ability to get needed care significantly lower than White patients (LS mean 81.9 (SE 2.46) vs. 86.7 (SE 1.75), p = 0.02); however, there was no difference in ability to get needed care between Black and White patients. Patient ratings for getting care quickly were lower in non-White patients, indicating racial disparities in perceived timeliness of care.